Position Summary:

Under general supervision of the Associate Nurse Executive (ANE), or designee, provides day-to-day operations management and oversees the functions and staff for the Continuum of Care Management Program (COC) at Alaska Native Medical Center (ANMC) as a front-line Manager. Supports the delivery of effective and efficient patient care.

Position Responsibilities:

• Overall accountability for the discharge planning and transition of care for patients within assigned caseloads of the Registered Nurse (RN) and Social Worker (SW). Ensures the discharge coordinators and social workers, with the patient, family and healthcare team, create a discharge plan appropriate to meet the patient's needs. Ensures the business support activities are completed daily. Provides daily mentoring and support to the staff.
• Provides supervision to the COC discharge planners, transition of care and social workers. Serves as a content specialist for the staff in the areas of Discharge Planning, Transition of Care and Social Work.
• Manages a reduced caseload.
• Maintains knowledge and compliance with Medicare Conditions of Participation for Discharge Planning and ANMC policies and procedures. Ensures Joint Commission and other regulatory standards are met and documented.
• Serves as a role model for the staff and is capable of performing the duties of a Discharge Planner, Transition of Care and Social Worker effectively.
• Collaborates with ANE to maintain appropriate staffing of the department and revises assignments daily to assure optimal coverage and distribution of workload. Consistently demonstrates the ability to establish appropriate departmental priorities on a daily basis.
• Coordinates the orientation of new employees to the department.
• Develops and implements policies, procedures, and protocols for the department functions, ensuring the Discharge Coordination, Transition of Care and Social Work process is current and assists patients from all over the state to attain appropriate healthcare.
• Oversees and maintains the department's quality improvement processes and activities.
• Facilitates patient flow through acute care to meet individual patient needs and to appropriately use acute care resources.
• Ensures collaboration with the patient, family, and other health care providers in the formation of overall goals and the plan of care, as well as decisions related to care and delivery of services. Ensures care provided meets the unique, physical and psychosocial needs of the patient.
• Facilitates patient/family/caregiver care conferences, when needed. Coordinates multidisciplinary Patient Care Conferences for patients with complex discharge needs
• Ensures the COC team demonstrates engagement and involvement of the patient/ family/ caregiver in the development of the care plan and transition of care. Conducts staff audits to ensure realistic, measurable, individual goals and interventions are related to each identified need based on assessment and assessments are completed within one day of admission with ongoing review as required.
• Collaborates with social workers for patients with complex needs and/or psychosocial, financial, or behavioral issues.
• Ensures transition of care between patients and health care providers to confirm continuity and coordination of care for patients who are transitioning from hospital to home or another care facility/provider.
• Promotion of quality outcomes, patient satisfaction, and cost-effective care delivery.
• Assists the health care team in identifying and securing appropriate services to address discharge planning needs.
• Participates in interdisciplinary rounds that promote comprehensive and coordinated care and monitors progress against goals. Reviews patient's length stay and anticipated discharge date in order to facilitate progression of stay with interdisciplinary team.
• Demonstrates ability to work as a team member and promote a team environment.
• Provides leadership in the integration of the team and communicates with the care on a daily basis.
• Works with Continuum of Care Services, other ANMC departments and the Regions to conceptualize issues and work toward access to appropriate levels of care.
• Collaborates with ANMC teams to maintain continual improvement in flow of patients, information and materials to accomplish successful return to primary care.
• Ensures delivery of the Important Message from Medicare (IMM) and Medicare Observation Outpatient Notice (MOON) according to hospital policy.
• Coordinates educational opportunities for the ongoing education and development of the COC staff.
• Maintains open communication with ANE regarding issues/problems within the department.
• Assumes responsibility for personal/professional growth by keeping abreast of changing hospital, departmental and regulatory standards.
• Collaborates with ANE in the development of the annual Performance Evaluations for the staff.
• Performs other duties as assigned.

KNOWLEDGE and SKILLS
• Knowledge of federal, state, and local laws, regulations, and resources.
• Knowledge research theory, medical ethics theory and practices.
• Knowledge of statewide continuum of care issues, health care issues and trends.
• Knowledge of healthcare terminology, anatomy, physiology and concepts of disease.
• Knowledge and ability to utilize evidence based practice to develop the plan of care and interventions.
• Knowledge of the hospital environment and how the services and functions interact.
• Knowledge of Alaska Native cultures.
• Knowledge of social work and RN discharge care coordination policies, practices and procedures.
• Knowledge of customer service concepts and practices.
• Knowledge of community resources, programs, and processes of the Regions.
• Skill in effective discharge planning and coordination across the continuum of care.
• Skill in identifying health care trends, expert level of social work and discharge care coordination services.
• Skill in assessing and prioritizing multiple requests by patients, families, and team members.
• Skill in effectively managing and leading staff, and delegating tasks and authority.
• Skill in interpersonal relationships, written and oral communication.
• Skill in presenting information to groups.
• Skill in operating a personal computer utilizing a variety of software applications.

MINIMUM EDUCATION QUALIFICATION

Bachelor's Degree in social work or nursing. Progressively responsible work experience may be substituted for nursing education on a year by year basis.

MINIMUM EXPERIENCE QUALIFICATION

Non-supervisory - Two (2) years of clinical experience in nursing or social work

AND

Supervisory - Two (2) years of supervisory experience.

MINIMUM CERTIFICATION QUALIFICATION
• Current registered nurse license in the State of Alaska or Licensed Clinical Social Worker.
• Current Basic Life Support card required.

PREFERRED EDUCATION QUALIFICATION

Master's Degree in nursing, healthcare, or social work.

PREFERRED EXPERIENCE QUALIFICATION

Experience in the Alaska Tribal Health System.

PREFERRED CERTIFICATION QUALIFICATION

Nationally recognized case management certification is preferred.

ADDITIONAL REQUIREMENTS

Depending on the needs of the organization, some incumbents in this job class may be required to obtain additional certifications or training in one or more specialty areas.