Job Summary: To facilitate a safe discharge and/or transition of care for patients from hospital, lower level of care or to the community. Initiates the discharge planning process, works with patient, family, responsible party and/or conservator. Collaborates and rounds with Case Managers to discuss discharge plan. Updates regularly on discharge progress Works with outside facilities, vendors and providers while following the guidelines set by the insurer, Medicare and Med-iCal Coordinates transfer for both higher level of care, and discharge to a lower level of care Attends multidisciplinary rounding Initiate referrals and arranges post-discharge services DME, SNF, HH including: physical therapy, safety evaluation, wound care, dialysis, and IV infusion Completes and documents Patient Choice Form per CMS regulation on all Home Health and SNF placements for all Medicare products Supply family with any additional requested resources i.e. Caregivers, Board and Care, or Assisted Living (ALF) Assists with discharge transportation Ensures that the patient, family, responsible party and/or conservator are aware of and in agreement with the DCP Collaborates to obtain appropriate authorization from managed health care plans for discharge needs Maintains Medi-Cal Administrative Placement Lists for submissions to Medi-Cal Understanding of SNF placements and level of care through understanding of Medi-Cal administrative daily process Monitors and assists/delivers the Medicare IMM’s (Important Message from Medicare) and the Patient Choice Form. Maintain ongoing and consistent communication with nursing, physician, patient, patient representative and case management regarding plan and updates. Document all interactions in Paragon Escalate any barriers or issues to the Leadership Team as they arise. Performs other duties as assigned
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Job Type
Full-time
Education Level
High school or GED
Number of Employees
1,001-5,000 employees