Overview

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.

Reporting relationship:

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

Responsibilities:

• 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
• Bedside visits:
  • 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

EDUCATION

Minimum High School diploma required.

Bachelor's degree preferred in a healthcare related field or equivalent combination of education and experience

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:

Medical/Dental/Vision plans

401 (k)

Vacation/Personal/Holiday/Sick Time Off

Short & Long Term Disability

Basic Life & Accidental Death Insurance

Tuition Reimbursement

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).