Discharge Planner, LVN – Care Management – Per Diem

Position Summary

Manages the discharge/transition process by working closely with the patient and/or family, and coordinating care with the multidisciplinary team: including physicians, nursing, and community based organizations, to ensure patient’s adequate post-acute care transition. Applies substantial knowledge and experience to perform a wide range of advanced activities and/or determines how to use resources to meet schedules and organizational goals; serves as lead for team or work group.

Essential Duties And Responsibilities

  • Assists patients through the healthcare system by operating as a patient advocate and health systems navigator.
  • Coordinates continuity of patient care with external healthcare organizations and facilities.
  • Obtains patient choice for post-acute facilities as required by CMS Conditions of Participation.
  • Coordinates referrals to post-acute facilities, including home care, DME, SNF, LTAC, Acute Rehabilitation based on patient/family choice when patient has Medicare.
  • Coordinates referrals to contracted facilities and vendors for managed care.
  • Reports care/discharge barriers to appropriate care manager.
  • Follow the continuum of patient care for admission to post-discharge.
  • Communicates with patients and families with regard to transition plans, as directed by the Care Manager.
  • Promotes clear communication amongst interdisciplinary care team members by ensuring awareness regarding patient care plans.
  • Coordinates special needs and projects as assigned (resource manuals, complex placement, recuperative care)
  • Knowledge of Medicare guidelines for post-acute needs IE: oxygen, wheelchairs, PT/OT/ST, feeding supplies
  • Performs other duties as assigned.

Position Requirements

  • Education
  • High school diploma or GED.
  • Licensed Vocational Nurse (LVN) License in good standing or BSW with 6 moths acute care experience.
  • Qualifications/Experience
  • 1-2 years healthcare facility experience preferred
  • Extensive discharge planning experience in an outpatient setting preferred.
  • A team player that can follow a system and protocol to achieve a common goal
  • Highly organized and well developed oral and written communication, problem-solving, and decision-making skills.
  • Special Skills/Knowledge
  • Current Basic Life Support (BLS) for Health Care Providers from the American Heart Association
  • Licensed Vocational Nurse License in good standing required.
  • Crisis Prevention Institute (CPI) Blue Card within 90 Days of hire or requirement notification.
  • Proficient to expert computer skills utilizing Microsoft Office especially Word and Excel
  • Medicare conditions of participation, general knowledge of Title XX11 benefits for medi-cal recipients
  • Critical thinking
  • Resourcefulness
  • Bi-lingual Spanish helpful but not required

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