• Responsible for coordinating the necessary care services to meet the patient’s needs to ensure a safe discharge.
• Function as the point of contact for all information related to the patient’s discharge.
• Manage all post-hospital care and follow-up through coordination of patient's discharge planning with multi-disciplinary teams
• Attend inter-disciplinary team meetings, and huddles, and initiate consults in support of patient’s discharge.
• Assist in securing transportation upon discharge
• Identify and provide patient-centered care for high-risk patients.
• Make daily rounds on units assigned to meet newly admitted patients.
• Coordinate and conduct discharge planning meetings on all inpatient units.
• Create and manage a patient discharge database and analyze data collected.
• Function as a liaison between patients and/or other health care facilities, other members of the disciplinary team, and community health services to ensure continuity of care.

Skills: Discharge Coordination, Team Collaboration, Patient Care, Post-Hospital Management, Planning Meetings, Transportation, Data Analysis, Healthcare Liaison 

• Evaluating and understanding the unique needs of each patient
• Identifying resources and treatment options accepted by patients’ insurance
• Completing timely discharge plans under the supervision of the program manager
• Documenting case management and discharge planning appropriately
• Accurately reflecting the progress of the client and treatment planning goals
• Collaborating with patients’ community care teams and existing providers
• Attending treatment team meetings when indicated
• Completing follow-up calls to scheduled and current clients
• Performing other administrative or clerical tasks

Skills: Needs Assessment, Insurance Coordination, Discharge Planning, Case Documentation, Progress Tracking, Team Collaboration, Meeting Participation, Follow-Up Support

• Attends appropriate Social Services related workshops and seminars.
• Applies learned knowledge and educates others.
• Participates in professional organizations related to Social Services.
• Meets daily with nursing staff to evaluate resident needs and progress.
• Assures discharge planning begins the day patients are admitted and is designed by patients and their families
• Oversees discharge planning process, utilizing the strengths of both case management and social services
• Ensure the appropriate resources and services are available and arranged for all rehab patients.
• Attends Medicare meetings to review current patient caseload, level of care, progress in therapy, and estimated length of stay.
• Research and negotiate patient needs with IDT or other resources during the discharge process.
• Communicates with third-party payor case management department/ insurance companies and provides documentation/communication
• Attends daily Administrative Meetings to facilitate communication regarding admissions, transfers, and discharges.
• Provides resources and education to patients/families during the discharge process.

Skills: Professional Development, Staff Education, Social Services Participation, Resident Needs Evaluation, Discharge Planning, Case Management Oversight, Resource Coordination, Third-Party Communication

• Collaborates with the RN case manager or Social work case manager to identify patients needing post-hospital vendor services.
• Facilitates communication with the post-hospital vendor to provide the needed information to support the handoff communication.
• Participates in interdisciplinary huddles to facilitate effective patient throughput/planning.
• Educates patients and families related to needs post-discharge, completes required forms, and informs them of the alternatives available to meet the patient's needs.
• Refer patients who require extended care post-discharge to post-acute care facilities.
• Collaborates care planning with the RN case manager and/or Social Worker to ensure no delays with patient transitions.
• Collaborates with community agencies to ensure the provider can support the patient’s level of care related to housing, financial, transportation, psychosocial, educational, home health, and home medical equipment needs of patients/families post-discharge.
• Keeps updated lists of community resources.
• Documents interventions and discharge plans in the patient’s medical record (Midas).
• Maintains customer focus and exceptional care by using AIDET and other department initiatives.
• Maintains current knowledge of trends related to case management and care coordination issues through attendance and active participation in continuing education and professional organizations.

Skills: Vendor Coordination, Team Collaboration, Patient Education, Care Referrals, Care Planning, Resource Coordination, Documentation, Professional Development

• Provides discharge planning services including referrals for Home Health services, durable medical equipment, nursing facilities, transportation, and a wide range of other referrals.
• Assists case managers with initial discharge interviews of inpatient admissions.
• Assists case managers with arranging DME, home health, transportation, and SNF placement.
• Assists case managers in completing discharge planning assessments.
• Follows Hospital policies and other regulations regarding discharge planning protocols
• Refers to Social Workers, Case Managers, and other hospital personnel appropriately regarding collaborating on a task, or when recognizing a certain task to be out of the discharge planner’s scope of practice.
• Assists with general office duties, e.g., copying, faxing, mailing, filing, data entry, etc.
• Attends and participates in regularly scheduled staff meetings including other department required meetings and educational programs.
• Assists with discharge planning, including meeting with patients and families to gather basic data and formulate an initial discharge plan.
• Functions and collaborates with readmission reduction team goals.

Skills: Discharge Planning, Referral Coordination, Case Management Assistance, Policy Adherence, Interdisciplinary Collaboration, Office Administration, Staff Meetings Participation, Readmission Reduction Support

• Case management or utilization review experience
• Recent acute clinical experience
• Experience working in Emergency Room
• Knowledgeable about legal principles of consent, healthcare proxies and advance medical directives
• Knowledge of healthcare payor systems and benefits including HMO, PPO, Worker's Comp, Medicare guidelines, and Medi-cal
• Must have excellent customer service skills
• Strong leadership ability, independent thinking, and decision-making ability
• Excellent analytical problem-solving skills, and sound judgment
• Excellent oral and written communication skills
• Proficient computer skills (MS Word, Excel, Outlook).

Qualifications: BS in Social Work with 3 years of Experience

• Clinical experience in an acute care hospital setting
• Experience working in community work and/or gerontology, discharge planning
• Current knowledge of community resources and initiative to proactively search for new resources
• Experience with legislation that governs Public Hospitals (Public Hospitals Act, Substitute Decisions Act, Consent to Treatment Act, etc.)
• Demonstrated extensive knowledge base of resources in the public and private sector, and medical and clinical language and procedures.
• Extensive knowledge of how to effectively serve an increasingly aging and diverse population with complex medical, functional, cognitive, and psychosocial needs
• Comprehensive knowledge of the impact of social determinants of health on discharge planning, hospital LOS, Patient Flow, and hospital system capacity
• Expert communication, collaboration, organizational and problem-solving skills
• Ability to work independently as well as with an interdisciplinary team
• Demonstrate the ability to set priorities
• Skilled working with a broad range of client groups and their significant supports

Qualifications: BS in Medical Laboratory Technology with 6 years of Experience

• Experience working in home health nursing.
• Strong clinical assessment skills and knowledge of medical standards of care.
• Ability to interrelate with physicians, nurses, and other hospital personnel.
• Knowledge of government, voluntary, and regulatory standards, requirements, and guidelines.
• Knowledge of principles related to the release of information and maintenance of confidentiality of data.
• Excellent oral and written communication skills.
• Knowledge of basic infection control practice.
• Knowledge of third-party payer systems and levels of care.
• Ability to work independently.
• Strong organizational and time management skills.

Qualifications: BS in Psychology with 1 year of Experience

• Hospital Case Management and/or discharge planning experience
• Knowledge of psychiatric disorders in the adult population
• Knowledge of Intellectual and Developmental Disabilities
• Knowledge of Substance Use Disorders
• Knowledge of Housing programs
• Knowledge of Intellectual Disability placement services
• Knowledge of inpatient substance abuse services
• Basic knowledge of the nature of addiction for referral purposes
• Effective communication skills, both oral and written. 
• Knowledge of behavior management, crisis intervention, and interventions common to acute psychotic consumers, as well as to non-violent crisis intervention practices
• Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. 

Qualifications: BS in Nursing with 4 years of Experience

• Experience working in behavioral health.
• Knowledge of addictions and mental health complications.
• Knowledge of community health resources that support life improvement in physical, emotional, mental, and spiritual health, economic security, employment, positive social and family interdependence, and positive cultural identity
• Knowledge of emergency procedures used in case of alcohol and/or drug overdose.
• Knowledge of the stages of alcohol and other drug withdrawals and ability to take appropriate action at each stage.
• Knowledge of Federal, State, and Municipal laws and/or regulations that regulate the treatment of alcoholism and drug addiction
• Strong administrative and organizational skills
• Strong written and verbal communication skills, including presentation and public speaking skills
• Must be proficient in Microsoft Office software
• Demonstrated ability to effectively multitask, prioritize, and mobilize community resources efficiently

Qualifications: BS in Health Administration with 5 years of Experience