Job Summary:

Develops and implements continuing care plans for patients that are being discharged from the hospital. Assesses the individual patient’s needs and works with the patient/family/caregiver/proxy to develop a plan of care that promotes the patient's return to the optimal level of wellness for their long-term health and prevents relapse. Works collaboratively with the patient(s), patient’s family members, friends, community support services, physicians, nurses, and other multidisciplinary team members to achieve this goal.

Job Duties:

Coordinates direct and implements discharge planning services for hospital inpatients. Screens admissions to the hospital for social services and discharge planning needs. Ensures timely discharge through early intervention identification of post-hospital care needs. Evaluates the home situation and assesses ability and resources available to care for the patient at home. Ensures continuity of care needs are assessed and met. Coordinates plan of care with patient, family, and physician. Assists patient and family to develop a realistic post-hospital plan of care that allows the patient to be safely discharged and arranges for home care needs such as home health, durable medical equipment, and community services. Develops and maintains ongoing relationships with area nursing homes, home health, and durable medical equipment agencies. Assists families to locate a nursing home or other post care facilities and assists placement if needed. Identifies quality improvement opportunities within the department to ensure efficiency and appropriateness of discharge plans and services offered. Keeps abreast of current regulatory requirements related to discharge planning including Medicare, Medicaid, and other third-party payer requirements. Reports and participates in the discharge planning committee and Utilization Management Committee providing in-service education as needed. Educates patient and family regarding Medicare and/or third payments for discharge needs. Refers patient to Patient Care Benefits coordinator as appropriate for assistance.

Keeps, updates and maintains a current list of available home health agencies, durable medical equipment (DME) companies, hospice, and long term care facilities. Educates hospital and medical staff regarding available discharge planning services, including the lead time necessary to obtain services. Attends and participates in morning report meetings. Collaborates and assists as needed with Inpatient Case Management. May perform supervisory duties as needed when the supervisor is not available and other duties as assigned.

SUPERVISORY RESPONSIBILITIES

Lead position.

Qualifications:

EDUCATIONAL REQUIREMENT

Bachelor's degree from 4-year College or University in Social Work, Nursing, or other health-related field; no substitutions.

EXPERIENCE REQUIREMENT

At least two years of experience in a related field.

COMPUTER SKILLS

An individual should have knowledge of Database software; Internet software; Spreadsheet software and Word Processing software.

CERTIFICATES, LICENSES, REGISTRATIONS

A Licensed Master's Social Worker (LMSW) is preferred; or Licensed Social Worker Associate (LSWA) with clinical experience; or Registered Nurse (RN) currently licensed by the Oklahoma Board of Nursing with case management or social service experience. RN must maintain current licensure throughout employment. Must possess a valid driver's license with a driving history verified through a motor vehicle report that meets requirements for Cherokee Nation underwriting rating. Must possess and maintain Basic Life Support (BLS) Certification or acquire within one (1) year of employment.

OTHER QUALIFICATIONS

Employee must not and will not be under sanction by the United States Department of Health and Human Services Office of the Inspector General (OIG) or by the General Services Administration (GSA) or listed on the OIG’s Cumulative Sanction Report, or the GSA’s List of Excluded Providers, or listed on the OIG’s List of Excluded Individuals/Entities (LEIE).

The discharge planner must be able to demonstrate empathy for their patients and work cooperatively to develop a plan of care the patient is likely to follow. The discharge planner must be well organized, managing facts such as third-party coverage for each patient. Good time management skills are an asset in that discharge planning involves coordinating meetings among doctors, outpatient care providers, family members, and support people. The Discharge Planner must have experience in internet, email, and EHR. This Discharge Planner must have demonstrated ability in the areas of interpersonal relations, critical thinking, and problem-solving and conflict resolution. Must meet and maintain pre-employment and periodic background investigation and adjudication for child care. Ability to assess patient status. Effectively communicates and possess interpersonal skills. Supports the mission, vision, and philosophy of Cherokee Nation Health Services.

PHYSICAL DEMANDS

While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to stand; walk; sit and use hands to finger, handle, or feel. The employee is occasionally required to reach with hands and arms; climb or balance; stoop, kneel, crouch, or crawl and taste or smell. The employee must occasionally lift and/or move up to 25 pounds.

WORK ENVIRONMENT

The noise level in the work environment is usually moderate

8s and 10s with rotating weekends