Episode Coordinator - Population Health - CMMC, Belleville, NJ
Rwjbarnabas Health Corporate Services
Health And Wellness Coordinator Job in Rutherford, NJ
The Episode Coordinator serves as a critical component of the value-based operations care management team. He or she will oversee coordination of care for all patients enrolled in one or more value based programs including CJR, MSSP, HRRP, and all other contracted programs while the patient is in an acute care setting.
For Medicare patients enrolled in Comprehensive Joint Replacement (CJR) lives, the Episode Coordinator s responsibility includes engaging the patient directly at the bedside, providing the beneficiary notification, and working with the patients interdisciplinary team which includes the patient, family, caregiver, Orthopedic service line coordinator, and clinical care team to coordinate an appropriate and safe discharge plan to a post-acute or home setting.
For Medicare patients enrolled in a Medicare Shared Savings Program (MSSP) and/or Hospital Reduction Readmission Program (HRRP), the Episode Coordinator will participate in interdisciplinary rounds and coordinate with the hospital care team to identify next site of care discharge disposition.
For all other contracted payers under population health, the Episode Coordinator will participate in interdisciplinary rounds and coordinate with the hospital care team to identify next site of care discharge disposition.
The Episode Coordinator will conduct a follow up phone call after the patient has been discharged from an acute care setting to home, to screen patients for safe discharge, and escalate any clinical issues to a Nurse Care Manager as needed for clinical interventions.
The Episode Coordinator reports directly to the centralized value-based operations care management team ensuring strong alignment and continuity of care for patients to avoid any overlapping outreach.
Episode Coordinators will be provided with a risk stratification tool and Value Based Care criteria to focus and prioritize efforts.
Episode Coordinators report to the Assistant Director, Post Acute Network under the AVP for Population Health.
Episode Coordinators currently service these locations:
Clara Maass Medical Center (CMMC)
Community Medical Center (CMC)
Cooperman Barnabas Medical Center (CBMC)
Jersey City Medical Center (JCMC)
Monmouth Medical Center (MMC)r
Monmouth Medical Center South Campus (MMCSC)
Newark Beth Israel Medical Center (NBI)
Robert Wood Johnson University Hospital
RWJ University Hospital Hamilton
RWJ University Hospital Rahway
RWJ University Hospital Somerset
Trinitas Regional Medical Center
Identification of CJR, MSSP, HRRP, and other patients attributed to a value based contract upon admission:
CJR patients are identified through the Ortho Service Line daily, via an Excel list that is provided to the Episode Coordinator s via a Shared Drive (patient tracking tool)
MSSP and other value based patients (Non/CJR patients) are identified through the Acute Admit program in Epic
HRRP lives are identified through the HRRP program in Epic
Email list of all CJR, MSSP, and CJR lives to (IP CM, PT, etc.) to identified key stakeholder daily
Episode Coordinator will stratify patient list each day and send patient list and assigned Care Manager to individual Inpatient Case Managers to alert them of VBC patient and initiate comprehensive discharge planning
Sign patients up for My Chart
Identify patient s home situation prior to admission
Schedule PCP follow up appointment. If the patient does not have a PCP assist patient in selecting a PCP and making the initial appointment
Assign a Pop Health Care Manager for High Risk Follow up
Ensure any specialist appointments are scheduled as needed
Engagement with CJR patients:
Distribution of Beneficiary Notification Letter for ER to Admission patients
Documentation of date/time letter give to patient
Confirming contact information and document information
Documentation of patient data and information in Epic Healthy Planet for CJR, MSSP, HRRP, all value based contracts patients. Specific documentation focuses on care at time of discharge within Epic: what happened, where they went, both level and name of facility, if applicable
Engagement with Care Management Director and Physician Advisors
Identify units with highest volume of VPC patients and discuss care planning, in real time, individual patients on the daily census
Daily touch base with Unit Case Management to facilitate appropriate next site of care
Actively communicates with discharge planners about patients with Post-Acute Care facility needs
Communication with Post-Acute Coordinators on patients going to facilities
Communication to Population Health Nurse care manager and VNA on patients going home with or without Home Health
Inform Case Management of readmissions
Minimum High School diploma required.
Bachelor's degree preferred in a healthcare related field or equivalent combination of education and experience
Experience in working in Health Care preferred
Experience in customer service role preferred
1+ years of customer service experience analyzing and solving customer problems required.
We offer a great work environment, competitive rates and excellent benefits, including:
Vacation/Personal/Holiday/Sick Time Off
Short & Long Term Disability
Basic Life & Accidental Death Insurance
Health Care/Dependent Care Flexible Spending Accounts
RWJBarnabas Health is the most comprehensive health care delivery system in New Jersey and the state s second largest private employer with more than 32,000 employees, 9,000 physicians and 1,000 residents and interns. The system includes eleven acute care hospitals, three acute care children s hospitals and a leading pediatric rehabilitation hospital (Children s Specialized Hospital).