About this role
• Performs care coordination services for assigned recipients who are eligible for home health services (Home Health Visits, PPEC, Personal Care Services and/or Private Duty Nursing Services etc. based on contract requirements).
• Uses discretion to approve/validate UR or forward to 2nd level reviewer. Provides first level utilization review for all inpatient and outpatient services requiring authorization: Prospective Review Urgent/ Non-urgent, Concurrent Review and Retrospective Review.
• Completes prior authorizations as appropriate in a timely manner.
• Conducts an initial survey to recommend appropriate (home health assessment) for the recipient, unless this has already been done during the current fiscal year
• Conducts a home and/or PPEC visit as needed or if contract requirement
• Schedules and convenes initial face-to-face meeting in the recipient's home and/or PPEC comprised of the recipient (if able) and the parent or legal guardian.
• Assesses, plans, implements, monitors and evaluates the options and services required to meet the recipient's health care needs.
• Documents recipient's assessment findings, actions, and outcomes.
• Documents all communication, interventions and follow up tasks in the Care Coordination System within one (1) business day of each intervention and/or encounter.
• Identifies patient care issues and makes recommendations on patient care issues.
• Collaborates with the parent or legal guardian and healthcare team to arrange for identified home care needs.
• Responsible for maintaining regular monthly contact (telephonically or face-to-face) with the recipient and the recipient's parent or legal guardian.for purpose of updating Plan of Care (POC), resolving issues and identifying additional issues
• As part of the multidisciplinary team, regularly meets with the team and contributes to the development of a comprehensive plan of care based on the needs of the recipient and recipient's parent or legal guardian.
• Evaluates and modifies recipient's the plan of care as needed. Regularly communicates changes to the recipient's parent or legal guardian, healthcare team, and other agencies involved in the recipient's care.
• Monitors assigned caseload eligibility status on a monthly basis, based on their status in MMIS.
• Completes a Staffing Tool (Freedom of Choice) any time a parent or legal guardian expresses the desire to reconsider a recipient's placement into a Skilled Nursing Facility
• Follow guidelines for additional required calls and visits for Skilled Nursing Facility (SNF) transitions to community settings for six (6) months.
• Functions as a resource to the community.