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Care Coordination/Disease Management
Goal
Provide care coordination utilizing a Unit Based Team to focus on early
identification of needs and discharge planning, daily evaluation of
patient progress toward specific outcomes, and communication with the
medical staff and payors to promote quality, cost-effective outcomes.
Care Coordinators (Nurse or Social Worker)
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Screen all patients on admission
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Provide ongoing review of medically complex patients
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Assist interdisciplinary team with
discharge plan of medically complex patients
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Monitor clinical process, quality and efficiency
Clinical Social Workers
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Address needs of patients with complex psycho social issues
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Assist/refer for financial needs
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Manage medical-legal issues, provide counseling
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Mediation and patient advocacy
Utilization Coordinators
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Conduct concurrent review of medical
necessity
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Provide payors with requested
clinical information
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Perform concurrent review of
physician documentation
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Review all patients in observation
status
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Report quality events
Specialty Nurses
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Provide education and consultation services
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Includes Diabetes Educator, WOCN
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Work closely with physicians to provide pathways, routine orders,
protocols
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CONTACT INFORMATIONFor more information call, 928
773-2220.
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Northern Arizona Healthcare - 1200 N. Beaver St., Flagstaff, Ariz.
86001 - 928 779-3366
Flagstaff Medical Center - 1200 N. Beaver St., Flagstaff, Ariz.
86001 - 928 779-3366
Verde Valley Medical Center - 269 S. Candy Lane, Cottonwood, Ariz. 86326 - 928
639-6000
VVMC - Sedona Campus - 3700 W. Highway 89A, Sedona, Ariz., 86336 - 928 204-3000
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