Provides department support for the Continuum of Care Team to facilitate discharge planning and ensure appropriate throughput of patients. Works with Case Managers, Transitional Care Coordinator, and Social Workers to ensure discharge plans are communicated to patients and families during hospitalization and post discharge to ensure continuity and identify clinical barriers. Enables a positive patient experience through the discharge process and connection to resources as needed.

Essential Duties:

• Partners with members of the Continuum of Care team both case managers and social workers (RN Case Manager, SW Case Manager) in an effort to provide patients and family members a smooth, coordinated patient transition from hospital to home and/or the next level of care.
• Partners with members of the Care Coordination team to ensure appropriate communication occurs at the point of discharge so that the patients transition is smooth. Provides timely post-acute contact and reinforces post discharge instructions as needed under the direction of the Transitional Care Coordinator.
• Under the direction and supervision of Transitional Care Coordinator, utilizes multiple referral platforms such as Enso care, e-fax and phone calls etc. to review post-acute referrals. Also reviews discharge instructions and discharge summary to understand patients post-acute plan of care and barriers to follow-up. Provides timely follow-up on all referrals.
• Under the direction and supervision of the Transitional Care Coordinator, participates in post discharge phone calls to patients. Uses scripts and follows the Cipher Health algorithm for communication with discharged patients.
• Under the direction and supervision of the Transitional Care Coordinator, communicates frequently and directly with clinic physician staff and other post-acute providers as needed for discharged patients with identified needs.
• Follows established policies and procedures and workflows regarding post discharge phone calls.
• Communicates the discharge plan, status of plan to members of the Continuum of Careteam, including allied health care team members. Participates in triad huddles and in the provisioning of assignments of the triad team.
• Contacts post-acute care facilities as directed by the Continuum of Careteam to assess bed availability, submission of referrals, bed-hold days. Utilizes multiple referral platforms such as faxing, Enso care etc. to facilitate referrals.
• Coordinates all non-clinical aspects of the discharge planning process as assigned (i.e. durable medical equipment, homeless shelters, non-clinical letters, transportation) reporting any psychosocial needs, barriers or challenges to the appropriate Continuum of Careteam member.
• Communicates frequently and directly with Continuum of Care team members regarding discharge process needs and priorities. Communicates orders received to the appropriate case manager, works with the Triad team for daily assignments and tasks needing to be completed. Hands off tasks and duties not performed.
• Participates in departmental meetings, including but not limited to staff meetings, daily huddles, triad huddles, and Continuum of Care team meetings, etc.
• Utilizes tools (i.e. Medicare.gov website, tablets for patient choice, etc.) as needed to provide patients with skilled nursing facilities and/or information on discharge planning resources within 10 miles or as close to the patients home as possible.
• Documents appropriately following departmental standards in the electronic Medical Record.
• Assists with transfer of patients for lateral and/or acute services.
• Supports the Continuum of Careteam with arranging transportation using Taxi, Ride Share, ambulance etc.
• Assists with maintaining and updating current resources (i.e. pamphlets and brochures) for services as needed for post acute care for use by care coordination team.
• Participates and engages in continuous improvement activities, including huddles and process improvement projects.
• Follow all departmental standard work and guidelines including the Triad Model of Discharge Planning. Support transitions of care.
• Develops and maintains positive working relationships with outside post-acute facilities and vendors to promote timely discharge/transfer.
• Thrives in a fast-paced, multi-faceted team environment, working well with the key stakeholders, meeting tight deadlines, and multitasking a variety of assignments.
• Strives to support and contribute to the success of the Continuum of Care teams outcome metrics, key performance indicators and /or departmental goals and objectives.
• Represents the department in a positive and professional manner.
• Floating between assignments and between Keck and Norris hospitals is required for management of department needs. On-call, weekend coverage and rotation to manage the discharge needs of the patients within the organization is expected.
• Supports the clinical process for transfer from one level of care to another as medically indicated by the patients needs. Able to apply clinical knowledge to reference InterQual Discharge Screens and clinical stability for discharge/transition to the next appropriate level of care.
• Completes clinical authorization process for the discharge medications.
• Performs other duties as requested/assigned by Director.

Required Qualifications:

• Req High school or equivalent
• Req Specialized/technical training Nursing Completion of an accredited vocational nursing program.

• Req 2 years 2-3 years clinical experience.

• Req Typing 40-55 WPM. Experience with computer data entry.
• Req Proficient in Microsoft Office Suite.
• Req Good organizational skills.
• Req Strong command of the English language.
• Req Good customer service skills.
• Req Ability to multitask and work effectively in a team environment.

Preferred Qualifications:

Required Licenses/Certifications:

• Req Licensed Vocational Nurse - LVN (CA DCA)
• Req Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date. (Required within LA City only)

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