Continuum Coordinator (C2) Discharge Planner

Primary Duties

• Actively engages patient and family during the discharge process and provides educational resources regarding choice, cost, and scope of services provided, i.e., Dialysis, Pharmaceutical, home infusion under the direction of senior staff.
• Facilitates referrals to home care agencies, rehabs, DME vendors, home infusion vendors and home lab, or other programs as directed by the Clinical Care Manager.
• Assists with prior approval/preauthorization from insurance for post acute care services.
• Proactively identifies and removes barriers by providing information and referral services/linkages to entitlement programs, insurance programs or other appropriate hospital resources as well as community-based organizations.
• Explains to patient/family the Medicare important notice, their appeal rights and 3-day qualifying hospital stay requirements for Sub Acute Rehabilitation coverage services if appropriate.
• Facilitates patient transfers to other healthcare organizations in accordance with hospital policies and all applicable State and Federal guidelines/ regulations and Joint Commission standards.
• Documents all information pertinent to the transitional plan of care.
• Provides information to patient/family regarding discharge planning, length of stay, appropriate use of health care resources and the appeal process.
• Makes timely referrals to appropriate community services based on identified needs that assures continuity of care through the progression of patient’s plan of care.
• Clearly documents discharge plan and provides appropriate information to post hospital care providers.

Patient Flow / Progression of Care

• Identifies variances in care reasons and escalates Clinical Care Manager or local leadership.
• Serves as a role model in an ever-changing environment which supports the hospital mission.
• Participates in unit-based interdisciplinary meetings in a patient centric manner.
• Develops and mentors C2 Discharge Planning Staff as necessary.
• Fosters team’s ability to work together and achieve desired outcomes.
• Identifies any avoidable days that contributed to increased length of stay and documents appropriately.
• Utilizes the teach back process to ensure patients/families are informed regarding their discharge plan.

Leadership

• Serves as a role model in an ever-changing environment which supports the hospital mission.
• Participates in unit-based interdisciplinary meetings in a patient centric manner.
• Develops and mentors C2 Discharge Planning Staff as necessary.
• Fosters team’s ability to work together and achieve desired outcomes.
• Recognize the strength and expertise of all members to develop and implement the most patient centric plan.

Minimum Qualifications

• Associate's degree in health-related field
• Three years of experience in health-related field
• Working knowledge of discharge planning and community resources preferred