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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 patients 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 suppliesDocuments in the patients medical record for continuum of care.Coordinates transportation arrangements according to insurance requirements or as needed to meet post discharge needsAssists 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 neededAttends Physician or Bedside Rounds as directed by the Case Manager or CM ManagerMay be requested to perform data collection or provide reportsTake the initiative with delivering careAssist with higher level of carePerforms other duties as assigned.POSITION REQUIREMENTS
A. Education
High school diploma or GED requiredMedical Assistant Training preferredB. 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 preferredHighly organized and well developed oral and written communication problem-solving and decision-making skillsSkills / Knowledge
Current Basic Life Support (BLS) for Health Care Providers from the American Heart AssociationProficient to expert computer skills utilizing Microsoft Office especially Word and ExcelCritical thinkingResourcefulnessBi-lingual Spanish preferred but not requiredMedicare conditions of participation general knowledge of Title XX11 benefits for medi-cal recipients#LI-YD1
Key Skills
GIS,JAWS,Military Experience,Business Management,Emergency Management,Joint Operations,Production Planning,Relationship Management,Strategic Planning,ERP Systems,Exercise Planning,MRP
Employment Type : Grant
Experience : years
Vacancy : 1
