Job Description
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 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.
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Coordinates referrals to contracted facilities and vendors for managed care.
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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.
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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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Provides education to patient and/or family in the use of equipment as needed
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Attends Physician or Bedside Rounds as directed by the Case Manager or CM Manager
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May be requested to perform data collection or provide reports
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Take the initiative with delivering care
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Assist with higher level of care
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Performs other duties as assigned.
Job Requirements
POSITION REQUIREMENTS
A. Education
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High school diploma or GED required
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Medical Assistant Training preferred
B. Qualifications/Experience
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Two (2) years continuous recent experience in a healthcare setting as unit clerk /care coordinator or similar position required.
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A team player that can multitask and can follow details – knowledge of CMS guidelines preferred
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Highly organized and well developed oral and written communication, problem-solving, and decision-making skills
C. Special Skills/Knowledge
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Current Basic Life Support (BLS) for Health Care Providers from the American Heart Association
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Proficient to expert computer skills utilizing Microsoft Office especially Word and Excel
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Critical thinking
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Resourcefulness
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Bi-lingual Spanish preferred but not required
- Medicare conditions of participation, general knowledge of Title XX11 benefits for medi-cal recipients
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