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