| Ability to perform a head-to-toe assessment on patients to assess for post-acute clinical needs and completed Transition Planning Assessment within 24 hours of admission excluding holidays and weekends |
| Ability to implement and revise the transitional plan of care as indicated by the patient's response to treatment and/or medical workup. |
| Ability to revise patients' post-acute plan of care as indicated by the patient's response to treatment, interpretation of laboratory values, knowledge of medications, knowledge of new onset diseases and chronic comorbidities. |
| Coordinates patient transition/discharge to designated facilities or community care services; acting as a liaison between the Patient/family, Provider, facility, and the community agency or service line. |
| Responsible for communication and hand offs to next level of care to ensure smooth transitions. |
| Demonstrates competency in the referral of individualized care needs of patients to the appropriate care service based on age, developmental needs, payor source, and necessary criteria. |
| Coordinates communication to achieve (patient, family, and physician) satisfaction while facilitating an appropriate, efficient, and cost effective discharge. |
| Assists in identifying and documenting avoidable delay days attributed to the following categories: Delay in Discharge; Delay in Treatment or Diagnosis; Care Management; Medical Staff/Physician; Discharge Planning. |
| Actively participates in weekly Complex Case Review meetings by providing valuable and relevant updates on patient status and next steps for the patient's continuum of care. |
| Ability to identify appropriate level of care for patients to: Skilled Nursing, Home Care, Transitional Care, Rehab, Hospice, Palliative Care, and/or private duty. |
| Participation in patient care rounds with multidisciplinary team. |
| Identify progress toward desired discharge outcomes with interventions and review of care plan as necessary. |
| Communicate with multidisciplinary team, patient/family any updates or modifications of transition plan. |
| Act as a liaison between facilities and maintains effective public relations between the hospital facilities and community agencies. |
| Perform chart reviews, patient assessments, interview staff/Provider, and patient/family, to make thorough and appropriate community referrals. |
| Generate and cultivate referrals based on patient needs and choice and comfort of acting independently. |
| Understanding of national healthcare regulations and financial impacts and educate multidisciplinary team members and patient/family. |
| Perform other job-related duties and assigned tasks as requested; which may include: cross training and/or other job functions as temporary work loads and volumes require. |
| Demonstrates the ability to deal with pressure to meet deadlines, to be accurate, and to handle constantly changing situations. |
| Participates in interdisciplinary care planning and attends care rounds; and coordinating information and care requirements with other care providers; resolving issues that could affect smooth care progression; fostering peer support; providing education to others regarding the care management process. |
| Contributes to team effort by accomplishing safe and efficient discharge outcomes. |
| Provides clinical education and support to patient and family around medical processes, procedures, treatments, medications and management of health and wellness. |
| Participates and leads care conferences with multi-disciplinary team. |
| Assesses complex social situations or resource needs. |
| Provides and explains as required the Medicare Observation and Outpatient Notification (MOON) letter and/or the Medicare Most Important Inpatient notification letter. |
| Assists clinical and support staff to make patient follow-up appointments as required. |
| Validates discharge education/documents are completed/medication scripts sent to pharmacy. |
| Documentation meets current standards and policies. |
| Manages and operates equipment safely. |
| Coordinates and supervises patient care as necessary. |
| Demonstrates an ability to be flexible, organized and function under stressful situations. |
| Demonstrates the ability to deal with pressure to meet deadlines, to be accurate, and to handle constantly changing situations. |
| Professional Requirements: |
| Adheres to dress code. |
| Completes annual educational requirements. |
| Maintains regulatory requirements. |
| Wears identification while on duty. |
| Maintains confidentiality at all times. |
| Attends department staff meetings as required within the department. |
| Reports to work on time and as scheduled; completes work in designated time. |
| Represents the organization in a positive and professional manner. |
| Actively participates in performance improvement and continuous quality improvement (CQI) activities. |
| Coordinates efforts in meeting regulatory compliance, federal, state and local regulations and standards |
| Communicates and complies with the Benefis Health System Mission, Vision and Values as well as the focus statement of the department. |
| Complies with Benefis Health System Organization Policies and Procedures. |
| Complies with Health and Safety Standards and Guidelines. |
