Description A Brief Overview Collaborates with all members of the health care team, patient and family (or significant others) to coordinate timely and efficient assessment of discharge planning needs and formulation of patient and family centered discharge plans.
What You Will Do - Collaborates with the bedside nurse and clinical team, meets with patient and/or family to complete an initial discharge planning assessment within 24 hours of patient admission. 25%
Identifies patients and families with complex psychosocial, financial and legal discharge planning needs requiring a Social Work referral - Develops, documents and implements a discharge plan consistent with individual patient needs and with patient and family goals 40%
Develops plans with attention to individual patient and family goals
Discusses estimated length of stay, treatment plan and discharge plan with attending physician and/or medical team
Ensures that the Interdisciplinary Care Plan and Discharge Plan are consistent with patients clinical course, continued care needs and covered services
Refers to appropriate alternate site agency(s) based on post discharge needs and patient choice
Provides linkage to community resources and UH network services to facilitate optimal care, and serves as liaison to community agencies. - Communicates/collaborates with the work team using a multidisciplinary approach. 20%
Provides guidance/consultation to peers/team regarding complex psychosocial and /or discharge planning issues/barriers.
Participates in Interdisciplinary Team rounding
Coordinates discharge teaching. Collaborates with bedside nurse and members of Interdisciplinary Team to support teaching efforts, with special attention to situations where patient and family education requiring teach back and show back are required - Collaborates with Case Management/Utilization Review to clarify patient status, plan of care, barriers to discharge and discharge readiness 15%
- Ensures timely completion of discharge, transfer and/or referral forms and discharge order
- Regulatory: Coordinates activities to ensure patients appeal rights under Notification of Hospital Discharge Appeal Rights
Additional Responsibilities - Performs other duties as assigned.
- Complies with all policies and standards.
- For specific duties and responsibilities, refer to documentation provided by the department during orientation.
- Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.
Qualifications Education - Graduate of an accredited school of nursing (Required) and
- Bachelor's Degree (Preferred)
Work Experience - 3+ years clinical experience (acute care) (Required) and
- 2+ years of experience in case management/discharge planning in an acute care setting (Required)
Knowledge, Skills, & Abilities - Sound clinical knowledge base (Required proficiency)
- Knowledge of Medicare, Medicaid and commercial payer regulations (Preferred proficiency)
- Computer skills (Required proficiency)
- Multi-tasks and prioritizes work (Required proficiency)
- Works autonomously (Required proficiency)
- Communicates effectively with persons of various backgrounds (oral and written) (Required proficiency)
- Maintain clinical competency regarding health care delivery/psychosocial issues/regulatory requirements. (Required proficiency)
- Leadership skills (Required proficiency)
- Teaching skills (Required proficiency)
- Maintains a calm, professional demeanor when dealing with internal and external contacts (Required proficiency)
Licenses and Certifications - CM Certificate (Preferred)
Physical Demands - Standing Frequently
- Walking Frequently
- Sitting Rarely
- Lifting Frequently 50 lbs
- Carrying Frequently 50 lbs
- Pushing Frequently 50 lbs
- Pulling Frequently 50 lbs
- Climbing Occasionally 50 lbs
- Balancing Occasionally
- Stooping Frequently
- Kneeling Frequently
- Crouching Frequently
- Crawling Occasionally
- Reaching Frequently
- Handling Frequently
- Grasping Frequently
- Feeling Constantly
- Talking Constantly
- Hearing Constantly
- Repetitive Motions Constantly
- Eye/Hand/Foot Coordination Constantly
Travel Requirements