RN / Orthopedic Nursing Job in Nashville, Tennessee / Hospital
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Description
Standard Qualifications: Job Summary The Bundle Coordinator is responsible for the coordinatation of care for all joint patients in CJR or BPCI bundle , as assigned. Primary responsibilities will include the at discharge and post discharge monitoring of this patient population. This individual will need an awareness of the high risk stratified patients and will have increased touchpoints with this patient population to ensure appropriate progression through care pathway. Any variation from the care pathway will need to be communicated back to designated surgeon/office staff. Develop and maintain key contacts in post discharge facilities to ensure open communication and care coordination for assigned patient populations. III. General Essential Functions: 1. Participate in the development, promulgation, and implementation of care coordination process standards relevant to service scope 2. For post-op/post-hospitalization 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 and notify providers of readmissions and significant clinical status changes as appropriate. 3. For CJR/BPCI bundle patients, oversee clinical pathway variance tracking and interact with appropriate staff regarding any variances. 4. Use of the eCW/Meditech clinical record to conduct care coordination activities and comply with associated policies and procedures including those for work flow and consistent documentation. 5. Maintain communication and documentation requirements as outlined by respective health plan, initiative, program, and/or department protocols. 6. Oversee and monitor activity related to his/her assigned patients to ensure compliance with associated policies and procedures and timeliness of completion. 7. Engage patients in taking a proactive role for managing their health, medications, treatment and rehabilitation needs, as well as attending all follow-up appointments. 8. Comply with associated policies and procedures and CMS requirements related to the bundle standards. 9. Ensure awareness of high risk patients and refer to appropriate community based health plans or programs. 10. Access health plan programs/other services on behalf of patients, as appropriate. Meet all other expectations and responsibilities of the program/initiative agreement as related to care coordination 11. For hospitalized CJR patients, be aware high risk stratified patients and escalate long stay/high cost cases per format and communicate and actively engage in potential disposition changes to assure an appropriate discharge as consulted by inpatient care team. 12. Attend and participate in program/initiative teleconferences, program enhancement trainings and meetings, as required.
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