Job Title: Discharge Coordinator & Case Manager (LPN)

Reports to: Director of Nursing Services (for LPN duties) and Social Services Manager or Executive Director (for Social Services duties)

Department: Nursing & Social Services

Classification: Salary (Exempt)

Position Summary: The primary purpose of this dual role is to provide primary care to specific residents under medical direction, with an emphasis on assessment, illness prevention, and healthcare management, while also assisting in planning, developing, organizing, implementing, evaluating, and directing social service programs. This includes ensuring medically related emotional and social needs of residents are met, particularly concerning discharge planning and case management.

Essential Duties and Responsibilities:

Resident Assessment and Care Planning:

• Confer with the Medical Director and attending physician regarding specific residents.
• Consult with the physician concerning resident evaluation and assist the Director of Nursing Services in planning and developing nursing services.
• Examine the resident and their records to distinguish between normal and abnormal findings to recognize early stages of serious physical, emotional, or mental problems.
• Determine when to refer the resident to a physician for evaluation, supervision, or directions.
• Assist in modifying the treatment regimen to meet the physical and psychosocial needs of the resident.
• Assist in the development of preliminary and comprehensive assessments of the nursing needs of each resident in furtherance of resident care planning policy.
• Assist in developing and implementing policies and procedures for identifying the medically related social and emotional needs of the resident.
• Evaluate social and family information and assist in determining a plan for social treatment.

Discharge Planning and Case Management:

• Initiate requests for consultation or referral.
• Perform administrative duties regarding assigned residents, such as completing medical forms, reports, evaluations, studies, and charting.
• Discharge planning, development, and implementation of social care plans and resident assessments.
• Case management.
• Meet with administration, medical and nursing staff, and other related departments in planning social services.
• Participate in community planning related to the interests of the facility and the services and needs of the resident and family.
• Assist in arranging transportation to other facilities when necessary.
• Refer resident/families to appropriate social service agencies when the facility does not provide the services or needs of the resident.
• Provide information to resident/families regarding Medicare/Medicaid and other financial assistance programs.
• Provide direct assistance and support to residents/families with the process of application, submission, and coordination with relevant programs and offices.
• Compile information on discharge plans and present to the appropriate committee as required.
• Work with emotional problems including assisting resident/family with anxieties and stress caused by illness and admission, difficulties in coping with residual physical disabilities, fears related to helplessness and death, and the need for institutional and specialized care.
• Assist in providing solutions for social and practical environmental problems, including seeking financial assistance, discharge planning (including collaboration with community agencies), and referrals to other community agencies when specialized assistance is required.
• Assist in interpreting social, psychological, and emotional needs of the resident/family to the medical staff, attending physician, and other resident care team members.
• Assist in obtaining resources from community social, health, and welfare agencies to meet the needs of the resident.

Nursing Care and Administration (LPN Specific):

• Implement and maintain established policies, procedures, objectives, quality assurance, discharge planning, completing care conference, UDA's.
• Interpret policies and procedures to the physician, resident, family members, and public.
• Make written and oral reports/recommendations to the attending physician, Medical Director, or Administrator concerning the status and care of the assigned resident.
• May administer services within the applicable scope of nursing practice, which may include catheterization, tube feedings, suction, applying and changing dressings/bandages, packs, colostomy, and drainage bags, taking blood, giving massages and range of motion exercises, and care for the dead/dying.
• Chart nurses’ notes professionally and appropriately, reflecting care provided and resident response.
• Chart all reports of accidents/incidents involving residents.
• Chart all changes in resident condition and the response to those changes.
• Chart all communications with the resident’s attending physician regarding the resident, treatment, or response to treatment.
• Perform routine charting duties in accordance with established policies and procedures and applicable state and federal regulations.
• Assist the Quality Assessment and Assurance Committee in developing and implementing appropriate plans of action to correct identified deficiencies.

General Social Services and Reporting:

• Interview residents/families as necessary and in a private setting.
• Perform administrative requirements, such as completing necessary forms, reports, etc., and submitting such to the Director.
• Involve the resident/family in planning social service programs when possible.
• Obtain information concerning residents' personal and family problems, past illnesses, etc., by developing a Social Service Data Record.
• Provide consultation to staff and community agencies to solve resident needs and problems through social service programs.
• Record and maintain regular Social Service progress notes indicating response to the treatment plan and/or adjustment to institutional life.
• Maintain a quality working relationship with the medical profession and other health-related facilities and organizations.
• Compile and maintain a social service directory listing available community resources.
• Coordinate social service activities with other departments as necessary.
• Make routine visits to residents and perform services as necessary.
• Maintain contact with the resident’s family, involving them with non-medical progress reports as necessary.
• Make written and oral reports/recommendations to the Administrator concerning the operation of the social service department.
• Assist in standardizing the methods in which work will be accomplished.
• Assist in making appointments for the resident/family as requested or appropriate.
• Perform charting duties as necessary.

Qualifications:

• Education and/or Experience:
• High School Diploma or equivalent.
• Graduate of an accredited Licensed Vocational or Practical Nurse program.
• Certificates and Licenses:
• Must possess an active license to practice as a Licensed Vocational Nurse or a Licensed Practical Nurse valid in this state.
• Other Specific Requirements:
• Must provide evidence of being free of tuberculosis infection upon hire and as set forth by the policies of the facility.
• Must be able to read, write, speak, and understand the English language.
• Must possess the ability to make independent decisions when circumstances warrant such action.
• Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel, and the general public.
• Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to long-term care.
• Must possess leadership and supervisory ability and the willingness to work harmoniously with and supervise other personnel.
• Must have patience, tact, a cheerful disposition and enthusiasm, as well as the willingness to handle difficult residents.
• Attend and participate in workshops, seminars, etc., to keep abreast of current changes in the long-term care field, as well as to maintain a professional status.
• Create and maintain an atmosphere of warmth, personal interest, and positive emphasis, as well as a calm environment throughout the facility.

Work Environment:

• Works throughout the facility (i.e., nurse’s stations, resident rooms, etc.).
• Moves intermittently during working hours.
• Is subject to frequent interruptions.
• Interacts with residents, personnel, visitors, government agencies/personnel, etc., under all conditions and circumstances.
• Is subject to hostile and emotionally upset residents, family members, personnel, and visitors.
• Communicates with the medical staff, nursing personnel, and other department supervisors.
• Works beyond normal working hours and on weekends and holidays when necessary.
• May be on call 24 hours per day, 7 days per week.
• Is subject to call-back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.).
• Is subject to injury from falls, burns from equipment, odors, etc., as well as to reactions from dust, disinfectants, tobacco smoke, and other air contaminants.
• Is subject to exposure to infectious waste, diseases, conditions, etc., including TB and the AIDS and Hepatitis B viruses.
• May be subject to the handling of and exposure to hazardous chemicals.

Physical and Sensory Requirements (with or without the aid of mechanical devices):

• Must be able to move intermittently throughout the workday.
• Must be able to cope with the mental, emotional, and stress of the position.
• Must possess sight/hearing senses or use prosthetics that will enable these senses to function adequately so that the requirements of this position can be fully met.
• Must function independently, have flexibility, personal integrity, and the ability to work effectively.
• Must meet the general health requirements set forth by the policies of this facility which may include a medical and physical examination.
• Must be able to relate to and work with ill, disabled, elderly, emotionally upset, and, at times, hostile people within the facility.
• Must be able to lift up to 25 pounds. Requires infrequent lifting of more weight up to 50 pounds.
• Occasional pushing and pulling of carts.
• May be necessary to assist in the evacuation of residents during emergency situations.

Job Type: Full-time

Pay: $68,000.00 - $78,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Flexible schedule
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• Day shift
• Monday to Friday
• Weekends as needed

Experience:

• Discharge planning: 1 year (Preferred)
• Case Management: 1 year (Preferred)

License/Certification:

• LPN (Preferred)

Ability to Commute:

• Aurora, CO 80014 (Required)

Ability to Relocate:

• Aurora, CO 80014: Relocate before starting work (Required)

Work Location: In person