As a member of an interdisciplinary team, collaborates with physicians, nurses and medical directors to coordinate, facilitate and expedite patient care services across the continuum. Responsible for assessing, coordinating, expediting and facilitating the transfer of hospital patients to appropriate post discharge level of care. Responsible for analyzing medical records for determining the appropriate level of care, quality of care delivered, and resource management.
- Discuss discharge goals and options with patients, families and interdisciplinary team. Provide education regarding the discharge process and the continuum of care after discharge from the hospital. Participates in family meetings as a part of interdisciplinary team. Participates in daily Collaborative Care Rounds.
- Assess the functional, mental, and physiological status of the patient in order to make an appropriate referral to the post discharge level of care to ensure appropriate continuing care.
- Review medical records, compile and analyze medical, nursing and ancillary data to provide an accurate patient assessments to facilitate patient transfer to the post discharge level of care.
- Interact with patient, medical, nursing, social service and other professional modalities to ensure all medical orders, patient care treatments, ancillary data and level of care are consistent with the discharge plan.
- Ensure continuity of medical care through the time of discharge; act as a resource person for the staff/department.
- Review medical records for appropriate resource utilization to reduce the delayed hospital days and length of stay.
- Document medical records in compliance with all relevant laws, rules and regulations.
- Communicate and arrange the appropriate transfer of the patient to the post discharge level of care and advise patient/family/guardian of the disposition.
- Prepare all state, federal, and hospital forms to ensure continuity of care, level of medical care and provides documentation and compliance to federal and state regulations.
- Communicate to patients and/or patient’s families when needed regarding the medical necessity of the hospital stay.
- Performs all other related duties as assigned.
Job Qualifications and Specifications
Registered Nurse with Bachelors Degree in Nursing or equivalent, with current RI license, Minimum of 5 years related clinical experience, demonstrating recent knowledge of case management, utilization review, quality assurance, discharge planning, third party payor regulations and community health. Experience must demonstrate high level of interpersonal skills, both oral and written, analytical skills, leadership abilities and effectiveness within a team environment.