Position Summary: We have an exciting opportunity to join our team as a Clinical Care Coordinator.
In this role, the successful candidate This position is responsible for care coordination across the continuum of health care delivery with emphasis on services incurred outside the inpatient hospital setting. Care coordination includes assessing healthcare needs, identifying problems and opportunities for improvement, implementing interventions, managing the patient care transition process, assisting patients throughout care episodes, coordinating and facilitating care for patients with complex and chronic conditions, and promoting evidence based healthcare services. This position provides services to support expected program outcomes of reduced admissions/readmissions, reduced emergency department visits, improved medication compliance, reduced gaps in care, improved patient care coordination, and increased patient satisfaction with the health care experience. The individual in this position serves as a clinical liaison, and must demonstrate awareness and recognition of the plan of care across the continuum in order to direct patient care issues. This position also provides clinical leadership for patient care coordination that is consistent with the philosophy and goals of the institution, the NYUPN Clinically Integrated Physician Network and the Network Integration Department. The position must foster and work in collaboration with internal and external providers, other NYULMC staff and payers to ensure the achievement of high quality outcomes for patients/families.
Attend and participate in program/initiative teleconferences, program enhancement trainings and meetings, as required.
Initiate/maintain professional development plan including goals for self-improvement and to sustain clinical and NYULMC competencies.
Assist with interviewing candidates for department positions, as requested.
Participate in the development, promulgation, and implementation of care coordination process standards relevant to service scope.
Act as a professional role model to all levels of staff by considering the needs and behaviors of specific patients in a culturally competent manner and incorporating expertise, critical thinking and related experience in care of patients and families
Meet all other expectations and responsibilities of the program/initiative agreement as related to care coordination.
Access health plan programs/other services on behalf of patients, as appropriate.
Identify high-risk patients from Epic, health plan or other sources (e.g., reports), and outreach to and engage with the patients, and refer patients to the appropriate community based, health plan or other programs.
Engage patients in taking a proactive role for managing their health, medications, treatment and rehabilitation needs, and follow-up appointments.
Oversee and monitor activity by other staff members as related to his/her assigned patients to ensure compliance with associated policies and procedures and timeliness of completion.
Maintain communication and documentation requirements as outlined by respective health plan, initiative, program and/or department protocols.
Use the Epic electronic medical record to conduct care coordination activities and comply with associated policies and procedures including those for work flow and consistent documentation.
For health plan/other patients, interact with relevant stakeholders (health plans, contracted NYUPN practitioners, other providers, office staff, etc.) and collaborate with relevant staff to support regular interactions with program/initiative patients.
For health plan/other patients receiving outreach for needed services, follow evidence based guidelines and contact standards to facilitate closure of gaps in care and encourage use of in network services.
For health plan/other patients receiving complex-integrated care coordination services, conduct a comprehensive assessment, identify problems/issues, establish goals, implement interventions, reassess needs, establish appropriate timeframe for frequency of follow-up activities, and provide closure and referral services, as appropriate.
For health plan/other patients who have been hospitalized, complete transition of care activities on a timely basis.
Provide care coordination for patients aligned with health plan collaborative accountable care agreements or other agreements, as assigned, and comply with associated policies and procedures and contractual requirements.
For BPCI initiative patients, oversee clinical pathway variance tracking and interact with appropriate staff regarding any variances across the continuum of care.
For post index stay BPCI initiative patients, conduct ongoing contact and follow-up with post-acute care providers and other providers on a timely basis and notify providers of readmissions and significant clinical status changes as appropriate.
For post index stay BPCI initiative patients, provide timely ongoing contact and follow-up with patient to ensure understanding of condition/clinical status, procedure, plan of care, and need for follow-up care.
For hospitalized BPCI initiative patients, follow the patient while hospitalized, escalate long stay/high cost cases per format and communication process and actively engage in potential disposition changes to assure an appropriate discharge.
For preadmission BPCI initiative patients, conduct a comprehensive preadmission assessment and education on a timely basis, follow up to assure needed services are in place, and contact providers as needed.
Bundled Payment for Care Improvement (BPCI) Provide care coordination for patients in the BPCI initiative, as assigned, and comply with associated policies and procedures and Center for Medicare and Medicaid Services requirements.
Minimum Qualifications: To qualify you must have a Licensure as a Professional Registered Nurse in NYS with current registration. Education: BSN or graduate of an accredited RN program with Bachelors degree in related health care field. Experience: Three to five years clinical experience in ambulatory care, managed care or acute medical-surgical experience in the care of the population targeted for care coordination. Competencies: Possesses demonstrated strengths in interpersonal communication, customer service, negotiation, conflict management, creative problem solving, clinical leadership, change management, work process organization and time management. Able to apply critical thinking and clinical expertise toward achievement of specific outcomes. Previously established ability to foster strong collaboration with co-workers, peers, physicians, nursing, and ancillary departmental support staff. Working knowledge of Microsoft Office (Outlook, Word, Excel and PowerPoint) and demonstrated proficiency in managing an electronic medical record such as Epic or a care/case management system..
Required Licenses: Registered Nurse License-NYS
Preferred Qualifications: Two or more years in health plan, home health care or ambulatory setting care/case management experience. Membership in care/case management and/or related professional organization. Certification in Case Management, American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) or Certified Professional Healthcare Quality (CPHQ). Epic proficiency. Masters of Science in Nursing or relevant health related field. Experience in Cardiovascular cases is a plus.
Qualified candidates must be able to effectively communicate with all levels of the organization.
NYU Langone Health provides its staff with far more than just a place to work. Rather, we are an institution you can be proud of, an institution where you'll feel good about devoting your time and your talents.
NYU Langone Health is an equal opportunity and affirmative action employer committed to diversity and inclusion in all aspects of recruiting and employment. All qualified individuals are encouraged to apply and will receive consideration without regard to race, color, gender, gender identity or expression, sex, sexual orientation, transgender status, gender dysphoria, national origin, age, religion, disability, military and veteran status, marital or parental status, citizenship status, genetic information or any other factor which cannot lawfully be used as a basis for an employment decision. We require applications to be completed online. If you wish to view NYU Langone Health's EEO policies, please click here. Please click here to view the Federal 'EEO is the law' poster or visit https://www.dol.gov/ofccp/regs/compliance/posters/ofccpost.htm for more information. To view the Pay Transparency Notice, please click here.
NYU Langone Medical Center, a world-class patient-centered integrated academic medical center, is one of the nation's premier centers for excellence in clinical care, biomedical research, and medical education. Located in the heart of Manhattan, NYU Langone is composed of four hospitals – Tisch Hospital, its flagship acute care facility; Rusk Rehabilitation; the Hospital for Joint Diseases, one of... only five hospitals in the nation dedicated to orthopaedics and rheumatology; and Hassenfeld Children's Hospital, a comprehensive pediatric hospital supporting a full array of children's health services across the medical center – plus the NYU School of Medicine, which since 1841 has trained thousands of physicians and scientists who have helped to shape the course of medical history. The medical center's tri-fold mission to serve, teach, and discover is achieved 365 days a year through the seamless integration of a culture devoted to excellence in patient care, education and research. For more information, go to www.NYULMC.org.