Discharge Planning Specialist
- Location: Gastonia, NC
- Posted: May 7, 2019
Using independent nursing judgment, will assess, plan, facilitate, and integrate care for patients from preadmission through transitions to post discharge (Continuum of Care), including the coordination of services for patients in need of Skilled Nursing and Assisted Living placement, Acute Rehab, Long Term Acute Care, Home Health Care Services, Durable Medical Equipment, Hospice, Palliative Care, VA services, and obtaining insurance authorizations for all post hospital needs when required. Participates in multidisciplinary planning rounds on assigned units when applicable. Consults with Benefit Eligibility Specialist on uninsured and underinsured patients. Serves as patient/family advocate and liaison with physician. The Discharge Planning Specialist will identify preventable readmissions. The Discharge Planning Specialist will serve on various committees as assigned. Identifies and reports avoidable days. Other duties as assigned.
Role includes ensuring discharge planning is in place for admission (within 48 hours in most cases) through discharge, including input and preferences for planning for discharge from patient and/or patient family or guardian. Completing any necessary documentation to facilitate timely and appropriate discharge planning (FL2s, PASARR requests). The Discharge Planning Specialist acts as a patient advocate in the multidisciplinary team. Discharge planning updates are documented ongoing as patient condition, needs, and/or preferences change in the medical record. The Discharge Planning Specialist should sign the patient's plan of care upon initial assessment and at discharge. The Discharge Planning Specialist should maintain a current workbook for assigned area with handoff tools utilized in case of absence or other coverage. Identification and documentation of avoidable days should be completed. Multiple computer programs are utilized and are part of daily documentation.
Bachelor's degree in nursing from a recognized college or university, Master's preferred. Certification in Case Management preferred. Current RN license to practice in NC (NC license or multi-state (compact) license). Three to five years nursing experience. Experience in case management, home health, quality and/or utilization management preferred. Thorough knowledge of general nursing principles, methods, techniques. Exemplary verbal and written communication, critical thinking, interpersonal , group, leadership, and negotiation skills. Ability to communicate well with patient, family, staff, and physician to promote positive outcomes. Proficient in computer skills and MS Office software.
EOE AA M/F/Vet/Disability