***Please note: this is a pool position, no guarantee of hours***
Under the direction of the Department Manager of Care Management and the immediate supervision of professional nursing and social work staff, assists with completing concrete tasks necessary to facilitate the smooth access of patients and families to agencies, transportation, and services within and beyond acute care. Ensures that all services are delivered in accordance with the mission statement and values of Confluence Health and Central Washington Hospital.
1. Primary Position Responsibilities
· Contacts agencies (Home Health, Durable Medical Equipment, Outpatient Centers, etc) to make post discharge arrangements for patients.
· Faxes referral to facilities (Nursing Homes, Rehabilitation facilities, Skilled Nursing Facilities, etc) as requested by RN Case Manager, Social Worker, pt or MD, once patient has been choiced.
· Prints/copies sections of the chart to fax or send to accepting agencies/facilities to ensure continuation of patient's treatment plan.
· Arranges transportation as directed by the RN Case Manager or Social Worker.
· Notifies RN Case Manager of any potential delays of moving the patient through the continuum.
· Maintains accurate, up-to-date documentation in the medical record and departmental records.
· Collaborates with RN Case Managers and other team members for optimal information throughout the continuum.
· Performs other related functions as assigned (whiteboard project, IMM Letter).
2. Assists in the development and growth of the Care Management Team.
· Consistently enhances professional growth and development through participation in educational programs, in-service meetings and workshops.
3. Assessment and Planning: As part of Nurse – Social Worker Team
· Sets priorities and demonstrates strong sense of urgency when appropriate in order to complete assignments in a timely manner.
4. Coordination and Implementation
· Excellent interpersonal skills are necessary in order to develop and maintain relationships with payers and post acute care facilities, communicating confidential information, communicating policies and dealing with a variety of CWH personnel and outside customers.
· Assures seamless transitions for the patient/family across the continuum of care by assuring complete and accurate communication prior to discharge/transfer with the team.
· Demonstrations knowledge of resources available in our area. Utilizes these resources effectively in discharge preparations.
· Prioritizes patients effectively in order to achieve timely and appropriate patient dispositions.
· Documents discharge planning activities in the chart.
· Coordinates completion of and transmits information to community agencies regarding transitional plan of care, i.e. home care, nursing home, other transfer/discharge destinations and services as directed.
· May assist RN Case Manager or Social Worker by offering choice of providers for DME, Home Health Agencies, or other resources as requested.
· Facilitates completion of Death Certificates when requested by Manger.
5. Clinical Communication – Demonstrates effective communication, documentation and interpersonal skills.
· Completes documentation of forms related to the discharge process; includes discharge disposition, Home Health Tracking sheets, actual destination in PM Conversation, IMM Letter, and Details of Transfer.
· Has RN Case Manager or MD, check over transfer orders for completeness.
· Contacts agencies regarding bed availability and accessibility, and procedures for admission, schedules visits pertinent to the plan for the continuum (e.g. dialysis), and keeps the RN Case Manager and/or Medical Social Worker informed of status.
· Develops strong working relationships with various community agencies in order to promote expedient discharges
· Fosters cordial, positive and professional interpersonal relationships with patients, family members, physicians, staff, nursing homes, community agencies, insurance companies and peers. Shows courtesy and consideration for others.
· Shows a full understanding of and compliance with the terms of the Confidentiality Agreement.
· Documentation for transfer includes pt's choice of facility, transportation arrangements and completion of Details of Transfer Ad Hoc form designating documents sent in the Transition of Care process.
Demonstrate Standards of Behavior and adhere to the Code of Conduct in all aspects of job performance at all times.
- High school diploma, or equivalent, one year of college credits.
- Three to five years of work experience in a health care setting.
- Knowledge of post acute care community resources.
- Must be currently certified in BLS, and recertified annually.
- Demonstrates effective interpersonal and communication skills.
- Demonstrates flexibility via an ability to adapt to changing priorities and regulations.
- Demonstrates tact, diplomacy, negotiation skills, and good customer relations.
- Ability to apply creative problem solving skills.
- Ability to prioritize assignments and effective time-management skills.
- Basic knowledge of clinical and psychosocial aspects of patient care.
- Ability to present a professional presence and appearance.
- Must be detail oriented, flexible, and committed to patient advocacy.
- Ability to work interdependently.
- Demonstrates skills in planning, organizing, and managing multiple functions and complex processes.
- Must possess basic computer skills related to Windows navigation, mouse usage, keyboarding, email communication and password management.
- Excellent verbal and written communication skills required.
- Knowledge of basic computer software programs.
- Knowledge of area community resources and referrals.
- Acute hospital experience.
- Knowledge of Medical Terminology with ability to pass exam with score of 80% accuracy at time of interview.