These Principal Accountabilities, Requirements and Qualifications are not exhaustive, but are merely the most descriptive of the current job. Management reserves the right to revise the job description or require that other tasks be performed when the circumstances of the job change (for example, emergencies, staff changes, workload, or technical development).

JOB ACCOUNTABILITIES:

COLLABORATION WITH CARE COORDINATION (CC) TEAM TO EXECUTE TRANSITION OF CARE (TOC) PLAN.

• Collaborates with Case Managers and Social Workers in baseline patient assessment to identify post hospital support and any discharge needs.
• Collaborates with Case Managers and Social Workers jointly to communicate and problem solve in the development of the TOC plan including offering choices and preferences for post-acute providers, available resources and sharing the expected discharge date and disposition.
• Ensures the patient and medical facility receives information on benefit coverage including partnering with payers when needed.
• Monitors progress towards meeting the TOC goals and escalates to Case Managers and Social Workers any barriers to achieving the recommended goals identified in the plan.
• Assures the patient and medical facility are kept informed of the progression of the TOC plan throughout the hospital stay.
• Coordinates all the necessary post discharge referrals and authorizations in collaboration with the CC team.
• Monitors and communicates with Case Managers and Social Workers regarding status of post hospital provider referrals, identification of barriers and/or progress in TOC goals throughout the day to promote timely discharge.
• Facilitates the transfer of a patient to an appropriate post-acute facility, by preparing documents for the receiving provider, assisting in obtaining physician signatures and providing assistance with transportation services.

DEPARTMENTAL GOALS & OBJECTIVES.

• Rounds with Case Managers and Social Workers on units to provide updates and/or receive direction on assistance needed.
• Delivers the Medicare “Important Message” (IM) and informs patient or medical facility of their right to appeal their discharge.
• Proactively identifies, communicates and resolves barriers that impede a timely TOC plan; escalate unresolved barriers to Case Managers and Social Workers or leadership.
• Actively participates in daily team huddles and CC department meetings.
• Contributes to team decision-making process in planning daily priorities, resolving barriers and conflicts with action plans and creative solutions.
• Collaborates with team members on interdependent tasks.
• Demonstrates initiative and flexibility in working with intra / interdisciplinary teams.
• Actively shares knowledge and information with team members.
• Builds and maintains relationships that foster trust and confidence.

COMMUNICATION.

• Maintains accurate, current and legible documentation according to department standards.
• Enters CC note in the electronic medical record as needed to capture the status of referrals / communication for each patient
• Captures patient / medical facility preference(s) and other key CC discussions and agreements in the electronic medical record.
• Enters final post-discharge provider and assures closure of discharge cases in Allscripts
• Provides clerical support as needed including copying, faxing, scanning and data entry.
• Completes all forms required for department reporting

CUSTOMER SERVICE.

• Demonstrates tact and respect for all customers.
• Actively builds positive relationships with all customer and partners.
• Uses effective communication skills to resolve issues in a timely, positive and productive manner.
• Willingly provides and accepts direct, constructive feedback to and from colleagues and leaders.
• Identifies and escalates quality and risk management concerns to CM leadership team.
• Complies with confidentiality policies, Health Insurance Portability and Accountability Act (HIPPA) regulations, and department standards when transmitting patient information to agencies or vendors as needed for patient placement and referral.

EDUCATION:

HS Diploma or General Education Diploma (GED)

TYPICAL EXPERIENCE:

1-year recent relevant experience.

SKILLS AND KNOWLEDGE:

Oral and written communication skills.

Interpersonal and time management skills

Ability to work effectively in a fast-paced environment with rapidly shifting priorities and competing demands.

Ability to work independently with a minimum of direction.

Ability to exercise discretion and prioritize tasks, seeking input as indicated.

Intermediate PC skills and word processing skills required.

PHYSICAL ACTIVITIES AND REQUIREMENTS:

See required physical demands, mental components, visual activities & working conditions at the following link: Job Requirements