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Care Coordination/Transition Planning * Proactively screen and assess the acuity and transitional needs of the patient. * Partners with the Interdisciplinary team to facilitate placement in a rehab, SNF, sub-acute, assisted living facility, or home with Home Health Care, as well as arrange DME and other services as ordered. * Identify appropriate consultative services that would enhance patients timely transitional plan. * Encourages and facilitates patient and family participation in all care team decisions. * Collaborates with post-acute services, care managers, and PCPs to ensure transition back to the home environment. |
Clinical Knowledge * Understands basic medical terminology and conditions for hospital treatment. * Understands consultative disciplines and the role they play in patient care. |
Communication and Documentation * Assures post-acute plan is addressed in daily rounds, keeping patient and family in mind while modifying the plan when appropriate. * Maintains appropriate and timely documentation to include specifics related to planning and coordination activities. |
Insurance and Utilization Management * Interfaces with Utilization review specialist to stay current on patients eligibility for admission, continuing stay, or readiness for discharge. * Identify and record episodes of avoidable delays due to the failure of progression of care processes. * Understands CMS requirements and Readmission penalties. |
Leading Multidisciplinary Team * Partners with the physician to organize the transitional plan for patient care. * Collaboration with nursing and specialty disciplines to facilitate the transition to a lower level of care. |
Resource Management * Evaluates the appropriateness of care delivery in the inpatient setting and communicates any discrepancies with the medical team. * Facilitates the management of care in an outpatient setting. * Takes a leadership role in identifying opportunities to reduce risk both financial and clinical, through analysis and resources consumption outcomes. * Assertively manage resource utilization while appropriately navigating patient movement along the continuum of care. |
Compliance/Safety * Stays current and complies with state and federal regulations/statutes and company policies that impact the employees area of responsibility. * If required for position, ensures all certifications and/or licenses are up-to-date and valid prior to expiration dates. * Completes all company mandatory modules and required job specific training in the specified time frame. * Responsible for reporting any safety related incident in a timely fashion through the Midas/RDE tool; attends all safety related training programs; performs work in a safe manner; monitors work environment for possible safety issues and ensures others are also performing work in a safe manner. |
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