Discharge Planner - Per Diem Days

Job Description

Job Description

Job Description

If interested, please apply online and send resume to View email address on ziprecruiter.com.  

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

1. Assists patients through the healthcare system by operating as a patient advocate and health systems navigator.
2. Coordinates continuity of patient care with external healthcare organizations and facilities.
   1. Obtains patient choice for post-acute facilities as required by CMS Conditions of Participation.
   2. Coordinates referrals to post-acute facilities, including home care, DME, SNF, LTAC, Acute Rehabilitation based on patient/family choice when patient has Medicare.
   3. Coordinates referrals to contracted facilities and vendors for managed care.
3. Reports care/discharge barriers to appropriate care manager.
4. Follow the continuum of patient care for admission to post-discharge.
5. Communicates with patients and families with regard to transition plans, as directed by the Care Manager.
6. Promotes clear communication amongst interdisciplinary care team members by ensuring awareness regarding patient care plans.
7. Coordinates special needs and projects as assigned (resource manuals, complex placement, recuperative care)
8. Knowledge of Medicare guidelines for post-acute needs IE: oxygen, wheelchairs, PT/OT/ST, feeding supplies
9. Documents in the patient’s medical record for continuum of care.
10. Coordinates transportation arrangements according to insurance requirements or as needed to meet post discharge needs
11. Assists with post-acute needs as requested by CM Leadership or RN Case Manager.
12. Provides education to patient and/or family in the use of equipment as needed
13. Attends Physician or Bedside Rounds as directed by the Case Manager or CM Manager
14. May be requested to perform data collection or provide reports
15. Take the initiative with delivering care
16. Assist with higher level of care
17. Performs other duties as assigned.

Job Requirements

POSITION REQUIREMENTS

A.  Education

• High school diploma or GED required
• Medical Assistant Training preferred

B.  Qualifications/Experience

• Two (2) years continuous recent experience in a healthcare setting as unit clerk /care coordinator or similar position required.
• A team player that can multitask and can follow details – knowledge of CMS guidelines preferred
• Highly organized and well developed oral and written communication, problem-solving, and decision-making skills

C.  Special Skills/Knowledge

• Current Basic Life Support (BLS) for Health Care Providers from the American Heart Association
• Proficient to expert computer skills utilizing Microsoft Office especially Word and Excel
• Critical thinking
• Resourcefulness
• Bi-lingual Spanish preferred but not required             
• Medicare conditions of participation, general knowledge of Title XX11 benefits for medi-cal recipients                    

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