Specialist Care Transitions-FT / Days

Job 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 team

Conducts a comprehensive patient / family assessment to ensure appropriate referrals to address psychosocial and socioeconomic needs

Identifies any barriers and provides clarity to determine realistic goals for the treatment plan

Demonstrates understanding of the patient's diagnosis / prognosis care needs and outcome goals of the treatment / care plan

Collaborates with IDT clinical team to develop transition of care plan

Patients have a discharge disposition assessed and plan initiated within hours of admission of scheduled workdays

Initiates and implements treatment plan modification through monitoring and re-evaluation to accommodate changes in treatment or progress

Communicates appropriate information between physicians, nursing units, administration and other disciplines to facilitate care transitions to ensure proper patient flow through the hospital system

Collaborates with other departments to ensure customer satisfaction and coordinate appropriate patient care

Works with the IDT clinical team to understand the patient's utilization plan, appropriateness of continued hospitalization, observation status, length of stay and quality issues

Demonstrates documentation to substantiate assessment planning implementing and evaluating of discharge plan in a clear concise organized timely manner

Identifies barriers to timely patient discharge and facilitates resolution of the barriers and appropriately reports non-acute days

Coordinates and provides hand off to other post-acute providers

Contributes to the overall LOS

Follows 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 flow

Qualifications

Required Education : Bachelors Degree in Social Work, Social Services, or Health Promotions

Required Experience : Computers skills a must as well as excellent communication and the ability to work collaboratively with other disciplines

Preferred Experience : Working knowledge of D / C planning, post acute services, or Medicare regulations

Required 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