Job Summary
- Coordinates team-based care to provide health services to individuals, through effective partnerships with patients, their caregivers/families, community resources, providers, and interdisciplinary teams.
- Coordinate and monitor the care for all patient needs from admission to post-discharge.
- Works closely and maintains an open line of communication with UR regarding any changes of care or transfer/discharge plans. Help to monitor and adjust patient statuses based on changing needs and conditions.
- Cover the UR department when the UR nurse is not available.
- Review incoming Swing Bed referrals/packets for possible admission.
- Coordinates continuity of care by providing timely transitions of care and referrals by sending timely discharge summaries/referrals to appropriate providers upon discharge.
- Coordinates discharge and post-discharge services (i.e. home health, hospice, DME, follow-up appointments, referrals, etc.).
- Answer all resident’s questions about their care, treatment plans, illness, and all other issues to the best of my ability.
- Act as the patient’s advocate and voice concerning the POC.
- Coordinate and monitor all services provided to the patient (i.e. PT, OT, ST, RT, nursing, social worker, physician, etc.) to ensure the patient receives appropriate services and documentation compliance.
- Communicate regularly with interdisciplinary team members, follow interdisciplinary plans of care, and patient progression to ensure compliance and meeting insurance criteria.
- Coordinate and monitor Weekly Interdisciplinary Team meetings.
- Monitor and maintain, with providers, current admission certification forms.
- Help with chart audits as needed.
- May facilitate and attend meetings between patients, families, care teams, payers, and/or community resources as needed.
- Compliance with HIPAA policy and procedures.
- Perform other duties as assigned.
Education and Experience
- Current Louisiana Licensed Practical Nurse (LPN) in good standing.
- Maintain current CPR/BLS certification.
- Successfully complete hospital orientation.
- Satisfactory completion of annual evaluation and competencies.
- 1-2 years of experience in clinical care coordination, case management, or nursing home or home health care coordination preferred, but not required.
Requirements
- Proficient in verbal communication, electronic health records, email functions, communication technologies, organizational skills, and documentation of records.
- Demonstrates evidence of essential needs/preferences of patients, excellent customer service, empathy/compassion skills, effective communication skills, goal-oriented/self-motivator/team player skills, collaboration skills, and patient/family member counseling skills to meet the needs/goals of the department and patients.
- Able to handle stressful situations due to patient/family interactions.
Additional Information
- Position Type: Full-Time
- Shift: M-F 8:00 – 4:30 PM
- Pay to be discussed upon interview.
- Reports to Director of Case Management/UR Nurse and C.N.O.
- Closing Date: 7/1/24