In support of patient progression practice, provides patient/family-focused interventions to support timely discharge outcomes. Facilitates the pace of the case for real-time completion of concrete interventions identified in the discharge plan. Using a variety of modalities, carries out discharge plan recommendations for the alleviation or resolution of social, financial, and emotional problems related to illness, healthcare, and rehabilitation, allowing a timely transition of a patient from the hospital to the most appropriate next level of care.

Activities include such things as preparing information to facilitate a patient's discharge/transfer, arranging equipment and transportation, and discussing plans with the patient and family. Documents her/his work in the patient's medical record per department requirements.

• Identifies patient and/or families requiring coordination of continuing care or community support through collaboration with case managers, social workers, and other members of the care team. Reviews medical records, attends rounds, and responds to patients' needs. Assists the case manager and/or social worker with implementing continuing care plans. Applies knowledge based on professional experience.
• Under the direction of a case manager and/or social worker, assists in the facilitation of an appropriate discharge for her/his patients in accordance with the patient's medical readiness and expected needs. Assists in coordinating a patient's discharge/transition to settings such as skilled nursing homes, home with home health, patients with medical equipment, etc.
• Prepares the patient and/or family for discharge by providing an explanation of the plan and what the patient/family can expect.
• When needed for a safe, expeditious, and effective discharge, engages other members of the care team to have the patients/families questions answered and ensures there is adequate resolution.
• Ensures that a discharge is facilitated in accordance with regulatory requirements, patient/family choice, financial resources, and third-party payer requirements.
• Places referrals to multiple agencies reflecting the recommended level of care from the Care Management team.
• Assists with a safe and effective handover to the next level of care by working closely with hospital staff, external agency liaisons, and care navigators.
• Completes screenings for patients regarding financial, psychosocial, physical, and medical needs to determine long-term care service supports.
• Coordinates with outside agencies and community members to ensure continuity of services after an LTSS (UAI) screening has been completed.
• Determines financial supports and refers patients/family members to local DSS or inpatient social workers to complete Medicaid applications or financial screenings.
• Assesses mental health needs prior to patients discharging to skilled nursing facilities to ensure appropriate services at time of discharge (understanding the need for a Level II PASRR report).
• Documents his/her work in the medical record, meeting the requirements of the organization and department. Submits reports as required by management on things such as productivity, patient progression barriers, or other focused studies.
• Enhances the quality of patient care by complying with policies, procedures, and the quality measures of the hospital and department. Identifies and reports any problems, conflicts, trends, or other potential issues to appropriate administrative staff.
• In addition to the above job responsibilities, other duties may be assigned.

Position Compensation Range: $22.39 - $35.82 Hourly

MINIMUM REQUIREMENTS

• Education: Bachelor's degree required; bachelor's of social work preferred.
• Experience: One year in healthcare or similar setting; hospital setting preferred.
• Licensure: None.

PHYSICAL DEMANDS
Job requires sitting for prolonged periods, standing/traveling, or use of assistive and climbing (stairs, steps). Proficient communicative, auditory, and visual skills. Attention to detail and ability to hear, speak, see, distinguish colors, read, and write legibly. Ability to lift/push/pull < 20 lbs. May be exposed to chemicals, blood/body fluids, and infectious disease.

COVID Vaccination Requirement and Guidelines

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