The Patient Care Coordinator is an integral part of a multidisciplinary collaborative effort to identify and deliver quality and cost efficient healthcare to patients on acute inpatient rehabilitation.  Liaison between persons served, the rehabilitation team, and external resources.  While the role is multifaceted, concentrated effort is given to the coordination of services; ensuring adequate discharge plans are in place, and completing utilization management and quality review activities.  The care coordinator teams with social services in meeting these efforts.  Also have primary responsibilities in the day to day areas of patient evaluation using the IRF-PAI, insuring timely and accurate completion of the IRF-PAI/CARE tool. Responsible for inputting the data, and electronically transmitting the data to Medicare/UDS.  In summary the patient care coordinator has responsibilities of case management, PPS coordination for inpatient rehabilitation, and assurance of compliance to regulatory standards. In addition, this associate is expected to adhere to and exemplify the St. Luke’s Standards of Excellence and the PMR associate-patient relationship policy.

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Care Coordination-

• Ensures the provision of care
• Communicates with internal and external resources and the persons served to ensure achievement of outcomes.
• Facilitates orientation that is appropriate to the services and the outcomes predicted for the persons served.
• Facilitates involvement of the persons served throughout the rehabilitation process.
• Ensures that learning needs identified for the persons served are met in a coordinated, comprehensive manner.
• Monitors coordination of care for appropriate intervention and use of preventive measures through team conference interaction, individual staff/patient education/communication and other record reviews.
• Assists team in determining appropriate LOS and discharge.
• Coordinates and assures communication with physicians regarding patients’ progress toward outcomes and plan of care.
• Reviews weekly with the persons served and their caregiver(s) progress toward goals and seeks input to relay to the treatment team.
• Periodically reviews and monitors documentation to assure medical necessity for inpatient rehabilitation as well as burden of care documentation for reimbursement justification.
• Coordinates completion of Rehabilitation Patient Assessment instrument on all assigned patients on the timetable established by CMS and ensures accuracy.

Complex Discharge Planning

• Works collaboratively with the rehabilitation social worker to facilitate the implementation of the discharge/transition recommendations. Facilitates the removal of barriers to implementation of the discharge plan.

Continuing Care/Insurance Reviews/Financial management of the stay

• Financial coordination while person served on inpatient rehabilitation consist of :
  • Communicates with external sources about a patient’s financial resources.
  • Uses the financial information available to facilitate team decision making about the provision of services for the persons served.
  • Facilitates conservation of resources.
  • Submits completed Rehabilitation Patient Assessment instrument (IRF-PAI) to CMS on the timetable established by CMS.
• Performs utilization management and quality review activities on all inpatient rehabilitation patients, assuring patients are receiving the appropriate level of care.
• Outcomes measurement:
  • Facilitates the gathering of appropriate information to assist in the follow-up activities of the organization in its analysis of program performance.
• Actively participates on the rehab outcome committee.

• Graduate of an accredited nursing program.
• Bachelors’ degree (preferred) with current RN license in State of Iowa
• Experience in Rehabilitation nursing.
• Minimum of 3 years clinical experience (required).
• Understands and applies human relation skills in individual and group interactions.