If you are interested please apply online and send your resume to MarisMartinez@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
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Assists patients through the healthcare system, under the direction of CM, by operating as a patient advocate and health systems navigator.
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Coordinates continuity of patient care with external healthcare organizations and facilities.
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Obtains patient choice for post-acute facilities as required by CMS Conditions of Participation.
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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.
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Follow the continuum of patient care for admission to post-discharge.
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Communicates with patients and families with regard to transition plans, as directed by the Care Manager.
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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)
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Knowledge of Medicare guidelines for post-acute needs IE: oxygen, wheelchairs, PT/OT/ST, feeding supplies
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Documents in the patient’s medical record for continuum of care.
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Coordinates transportation arrangements according to insurance requirements or as needed to meet post discharge needs
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Assists with post-acute needs as requested by CM Leadership or RN Case Manager.
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Performs other duties as assigned.