Discharge Planner - RN

HHC•Indianapolis, IN

12d

About The Position

The Discharge Planner is responsible for managing each assigned patient's plan of care, monitoring appropriate resource utilization, and coordinating discharge planning. The role coordinates care across the continuum and works closely with Social Work, physicians, the interdisciplinary team, nursing, and patients and families to support timely, efficient care and serve as a patient advocate. The position includes case management, utilization review, financial assessment, and social assessment/discharge planning. The Discharge Planner assesses patient needs, helps resolve barriers and delays, monitors changes in condition and plan effectiveness, and documents case management and discharge-planning information. The role also oversees discharges and facilitates transitions to post-acute services and home health care.

Requirements

Current Indiana Registered Nurse (RN) license.
Minimum of 2 years of health care experience.
Knowledge of case management, patient education, and managed care processes.
Effective communication skills and knowledge of disease processes and normal growth and development across age groups to understand patient symptoms accurately.
Competency in interpersonal, written and verbal communication, and negotiation skills.
Diplomacy, flexibility, and professionalism.
Ability to network cohesively with the interdisciplinary team.

Nice To Haves

2 years of clinical nursing experience preferred.

Responsibilities

Coordinate care for assigned patients across the continuum in collaboration with Social Work, physicians, the interdisciplinary team, nursing, and patients and families.
Manage each patient's plan of care, monitor appropriate resource utilization, and coordinate discharge planning.
Advocate for patients and deliver quality, efficient health care.
Maintain active communication with the care team and patients and families to support timely progression through the plan of care.
Address problems that impede diagnostic or treatment progress and proactively identify and resolve discharge delays.
Use conflict resolution, critical thinking, and negotiation to resolve issues and identify strategies to reduce length of stay and resource consumption.
Interview patients and use relevant sources to assess medical, social, and financial needs and develop a comprehensive plan of care.
Collaborate with Transition Support Leadership and the Physician Advisor on cases requiring special intervention.
Document avoidable days and quality indicators as appropriate.
Participate in developing an action-oriented, time-specific plan of care and continually reassess patients for changes that may require a clinical pathway, revised plan, or change in care acuity.
Conduct or oversee initial admission reviews using appropriate criteria within 24 hours of hospital admission to assess level-of-care appropriateness and timely treatment-plan implementation.
Educate physicians, the interdisciplinary team, and nursing about payer sources and their role in discharge planning.
Communicate with on-site private payer or managed care case managers and address private payer denials as appropriate.
Evaluate patient funding and communicate with Financial Counseling or Med Assist to facilitate appropriate funding applications.
Address financial barriers to health care or medical compliance with patients and families when indicated.
Oversee discharges for assigned patients and collaborate closely with Social Work on discharge planning.
Facilitate discharge to post-acute services, including LTACs, skilled nursing facilities, and nursing homes, and coordinate home health care and durable medical equipment.
Document relevant case management and discharge-planning information in the medical record.