Job Category: Case ManagementJob Description:Care transitions non-RN is responsible for the clinical aspects of determining the appropriate discharge plan for patients in the acute care setting. This member of the care transition team will be responsible for facilitating and coordinating a safe appropriate discharge plan while meeting the patient's individual needs as well as state and federal regulations. This position works collaboratively with multiple other disciplines throughout the organization and community.Responsibilities:Coordinates patient care from admission to discharge in collaboration with RN and clinical teamConducts a comprehensive patient/family assessment to ensure appropriate referrals to address psychosocial and socioeconomic needsIdentifies any barriers and provides clarity to determine realistic goals for the treatment planDemonstrates understanding of the patient's diagnosis/prognosis care needs and outcome goals of the treatment/care planCollaborates with IDT clinical team to develop transition of care planPatients have a discharge disposition assessed and plan initiated within hours of admission of scheduled workdaysInitiates and implements treatment plan modification through monitoring and re-evaluation to accommodate changes in treatment or progressCommunicates appropriate information between physicians, nursing units, administration and other disciplines to facilitate care transitions to ensure proper patient flow through the hospital systemCollaborates with other departments to ensure customer satisfaction and coordinate appropriate patient careWorks with the IDT clinical team to understand the patient's utilization plan, appropriateness of continued hospitalization, observation status, length of stay and quality issuesDemonstrates documentation to substantiate assessment planning implementing and evaluating of discharge plan in a clear concise organized timely mannerIdentifies barriers to timely patient discharge and facilitates resolution of the barriers and appropriately reports non-acute daysCoordinates and provides hand off to other post-acute providersContributes to the overall LOSFollows 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 flowQualifications:Required Education: Bachelors Degree in Social Work, Social Services, or Health PromotionsRequired Experience: Computers skills a must as well as excellent communication and the ability to work collaboratively with other disciplinesPreferred Experience: Working knowledge of D/C planning, post acute services, or Medicare regulationsRequired Certifications and Licensures: Hold a current, active American Heart Association Basic Life Support (AHA BLS) course completion card.Preferred Certifications and Licensures: CCM Certification Care Coordination and Transitions Management Certification
