Coordinates patient care from admission to discharge in collaboration with RN and clinical team
Conducts a comprehensive patient/family assessment to ensure appropriate referrals to address psychosocial and socioeconomic needs
Identifies any barriers and provides clarity to determine realistic goals for the treatment plan
Demonstrates understanding of the patient's diagnosis/prognosis care needs and outcome goals of the treatment/care plan
Collaborates with IDT clinical team to develop transition of care plan
Patients have a discharge disposition assessed and plan initiated within hours of admission of scheduled workdays
Initiates and implements treatment plan modification through monitoring and re-evaluation to accommodate changes in treatment or progress
Communicates appropriate information between physicians, nursing units, administration and other disciplines to facilitate care transitions to ensure proper patient flow through the hospital system
Collaborates with other departments to ensure customer satisfaction and coordinate appropriate patient care
Works with the IDT clinical team to understand the patient's utilization plan, appropriateness of continued hospitalization, observation status, length of stay and quality issues
Demonstrates documentation to substantiate assessment planning implementing and evaluating of discharge plan in a clear concise organized timely manner
Identifies barriers to timely patient discharge and facilitates resolution of the barriers and appropriately reports non-acute days
Coordinates and provides hand off to other post-acute providers
Contributes to the overall LOS
Follows CMS guidelines with regards to observation notice (OBN) and inpatient notice (IMM)
Identifies patients requiring crisis intervention and acts as soon as possible to resolve the issue(s) and prevent barriers to patient flow
Required Education: Bachelor's Degree in Social Work, Social Services, or Health Promotions.
Preferred Experience: 2+ years of discharge planning, care coordination, insurance, acute care, or skilled nursing experience.
Required Experience: Computers skills a must as well as excellent communication and the ability to work collaboratively with other disciplines.
Preferred Certifications and Licensures: CCM Certification Care Coordination and Transitions Management Certification
