Job Summary

Works under the direction of the Director of Case Management to provide administrative support and the RN and/or Social Worker to complete referrals for post-acute services for patients and assists with tasks that do not require a clinical license or degree.

Job Specific Duties

• Assists patient and families; ensures that they are provided with post-acute care services as ordered by the physician. 
• Provides patients and families with choices of post-acute providers per policy. 
• Provides Medicare patients with the Important Message from Medicare (IM Notice), MOON, and HOON as required by CMS guidelines, policy, and compliance standards.
• Responds to post-acute providers timely and completes referrals and confirmation of services as indicated. 
• Works collaboratively with Case Management and Social Work teams to ensure timely, safe, and effective implementation of discharge plans to avoid delays in discharge and prevent avoidable readmissions. 
• Ensures documentation is completed accurately, thoroughly, and within standard of 24 hours (e.g., discharge planning). 
• Ensures appropriate continuing care services are in place for assigned patient transitions by assisting with the arrangements of services (home health, DME, transportation, nursing facility, etc.). 
• Interacts with vendors, payer, and community partners to facilitate safe transitions for patients. 
• Manages discharge planning referrals, responses, transportation, and required authorizations. 
• Coordinates follow-up appointments; gathers information and facilitates scheduling appointments with specialists/primary MD. Prioritizes appointments to prevent discharge delays.
• Communicates scheduled appointments with patient/family and healthcare team. 
• Works on confirming post-acute care services timely to avoid delays in discharge and escalates barriers to discharge as they are identified.
• Maintains contact with patient's legal guardian during hospitalization to explain treatment program and address any concerns or questions, following up promptly on all areas of concern. 
• Coordinates and participates in patient and family meetings as it relates to discharge plans. 
• Maintains ongoing and effective communication with patients, families, and other members of the health care team regarding status of post-acute care services and provides patients / caregivers with information on the provider(s) that will provide the post-acute care. 

Minimum Job Requirements

• 2 years of previous experience in a healthcare or health related setting with coordination of care experience
• Experience in coordination of medical appointments and services

Knowledge, Skills, and Abilities

• Associate's degree in healthcare preferred
• LPN preferred
• Knowledge of managed care benefits and coverage of services and post-acute care
• Familiarity with Microsoft Office, Word, PowerPoint, Excel, Visio, Cerner Clinical Documentation system
• Excellent oral/written communication, interpersonal, and organizational skills
• Ability to aggregate and analyze data
• Able to adapt and react calmly under stressful situations
• Able to handle multiple assignments, set priorities, and meet deadlines
• Strong ability in prioritizing, problem solving, and attention to detail
• Able to work in a team environment
• Ability to arrange post-discharge services
• Ability to communicate effectively with patients, families, providers, and other members of the care team