Care Guide Discharge Planning
About The Position
The Care Guide II supports Acute/Post Acute care coordination and discharge planning activities by partnering with hospital and post-acute case management teams, internal nurses, and post-acute providers. This role focuses on executing discharge plans, facilitating communication, and ensuring timely coordination of services to support safe transitions of care and reduce readmissions. The Care Guide operates within a structured model alongside utilization management and post-acute services with defined outreach cadences, escalation pathways, and collaboration across interdisciplinary teams.
Requirements
- Support inpatient case tracking and coordination for high‑risk and readmission‑prone populations.
- Partner with hospital/post-acute Case Managers and Discharge Planners to align on clinical status, discharge plans, and barriers to timely discharge.
- Coordinate post‑acute services, including Home Health, DME, and facility placements (SNF, IRF, LTACH, subacute) in collaboration with post‑acute teams.
- Conduct regular outreach to hospital/post-acute teams to monitor discharge progress and identify barriers.
- Serve as a liaison between hospital partners, internal nursing teams, and post‑acute providers to ensure alignment and timely execution of discharge plans.
- Escalate complex cases, clinical concerns, or discharge barriers to care managers or leadership as appropriate.
- Participate in interdisciplinary communication, reporting, and discharge planning activities.
Responsibilities
- Support inpatient case tracking and coordination for high‑risk and readmission‑prone populations.
- Partner with hospital/post-acute Case Managers and Discharge Planners to align on clinical status, discharge plans, and barriers to timely discharge.
- Coordinate post‑acute services, including Home Health, DME, and facility placements (SNF, IRF, LTACH, subacute) in collaboration with post‑acute teams.
- Conduct regular outreach to hospital/post-acute teams to monitor discharge progress and identify barriers.
- Serve as a liaison between hospital partners, internal nursing teams, and post‑acute providers to ensure alignment and timely execution of discharge plans.
- Escalate complex cases, clinical concerns, or discharge barriers to care managers or leadership as appropriate.
- Participate in interdisciplinary communication, reporting, and discharge planning activities.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
