Discharge Planner - Per Diem Days

If interested, please apply online and send resume to yadeleon@mlkch.org.

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
• Documents in the patient’s medical record for continuum of care.
• Coordinates transportation arrangements according to insurance requirements or as needed to meet post discharge needs
• Assists with post-acute needs as requested by CM Leadership or RN Case Manager.
• Provides education to patient and/or family in the use of equipment as needed
• Attends Physician or Bedside Rounds as directed by the Case Manager or CM Manager
• May be requested to perform data collection or provide reports
• Take the initiative with delivering care
• Assist with higher level of care
• Performs other duties as assigned.