Martin Luther King, Jr. Community Hospital Los Angeles , CA 90009
Posted 1 week ago
If you are interested please apply online and send your resume to MarisMartinez@mlkch.org
POSITION SUMMARY
Manages the discharge/transition process by working closely with the patient and/or family, and coordinating care with the multidisciplinary team: including physicians, nursing, and community based organizations, to ensure patient's adequate post-acute care transition. Applies substantial knowledge and experience to perform a wide range of advanced activities and/or determines how to use resources to meet schedules and organizational goals; serves as lead for team or work group.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Assists patients through the healthcare system, under the direction of CM, by operating as a patient advocate and health systems navigator.
Coordinates continuity of patient care with external healthcare organizations and facilities.
Obtains patient choice for post-acute facilities as required by CMS Conditions of Participation.
Coordinates referrals to post-acute facilities, including home care, DME, SNF, LTAC, Acute Rehabilitation based on patient/family choice when patient has Medicare.
Coordinates referrals to contracted facilities and vendors for managed care.
Reports care/discharge barriers to appropriate care manager.
Follow the continuum of patient care for admission to post-discharge.
Communicates with patients and families with regard to transition plans, as directed by the Care Manager.
Promotes clear communication amongst interdisciplinary care team members by ensuring awareness regarding patient care plans.
Coordinates special needs and projects as assigned (resource manuals, complex placement, recuperative care)
Knowledge of Medicare guidelines for post-acute needs IE: oxygen, wheelchairs, PT/OT/ST, feeding supplies
Documents in the patient's medical record for continuum of care.
Coordinates transportation arrangements according to insurance requirements or as needed to meet post discharge needs
Assists with post-acute needs as requested by CM Leadership or RN Case Manager.
Performs other duties as assigned.
POSITION REQUIREMENTS
A. Education
B. Qualifications/Experience
C. Special Skills/Knowledge
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Martin Luther King, Jr. Community Hospital