Discharge Planning Coordinator - Value Based Service Org - Full Time 8 Hour Days (Non-Exempt) (Non-Union)

Provides department support for the Case Management team to facilitate discharge planning and ensure appropriate throughput. Works with Case Managers and Case Management Assistants to ensure discharge plans are communicated to patients and families and enables a positive patient experience with the discharge process. Follows up post discharge with patients to ensure arranged post acute services are provided as ordered and patients are satisfied with the discharge process and with agencies providing the services.

Under the supervision of the ambulatory care manager, the care coordinator provides care coordination services required to meet an individual's health care needs to promote cost-effective, quality outcomes. Assists members of the health care team in the management of specific patient populations in the inpatient and outpatient settings. The care coordinator role assists the ambulatory care manager with the functions of complex case management, utilization management, quality management, discharge planning, and Transitions of Care (TOC) with the coordination of post-hospital care services, including transfers to an alternative level of care.

Responsibilities

• Works with the ambulatory care management nurse to manage a caseload, supporting up to 200 commercial outpatients.
• Contributes to the Transitions of Care (TOC) process, with coordination of post-acute services for specific populations in the outpatient setting.
• Collects data from multiple sources and works with the ambulatory care management nurse to assess patient needs.
• Collects data in collaboration with patient, family, physician, health care team, and works with the ambulatory care management nurse to develop a plan of care.
• Collaborates with the ambulatory care management nurse to ensure a specific plan of care is in place for all patients. Assists the ambulatory care management nurse with the timely completion of all delegated assigned tasks from the associated plan of care. Provides coordination of care such as scheduling members’ appointments; arranging transportation, etc., as outlined in policy and procedures.
• Actively participates in interdisciplinary meetings and team huddles.
• Answers phone calls from providers, facilities, or patients related to the status and processing of requests received from the ambulatory care management nurse.
• Assists with data collection for ongoing discharge planning needs, documents changes in the computer system under the direction of the ambulatory care management nurse.
• Demonstrates a collaborative working relationship with social workers to ensure patient psychosocial needs are met.
• Demonstrates a collaborative working relationship with care team members, including pharmacy, behavioral health, field team, office staff, and facility staff.
• Assists the health care team with identification of patient/family educational needs for discharge.
• Informs patient/family of the discharge plan and involves them in decision-making regarding care.
• Works with the Transitions of Care process to deliver post-acute services to address educational needs and ensure a safe discharge plan.
• Works with patient/family to learn self-management methods for ongoing monitoring and treatment of chronic conditions.
• Proposes alternative treatment options to ensure a cost-effective and efficient plan of care.
• Identifies and creates solutions to remove barriers that may impede optimal patient care.
• Completes case management care plans, including delegated tasks and interventions, that effectively prevent ER visits, hospital admissions, or readmissions.
• Works with the ambulatory care management nurse to ensure (InterQual or MCG) concurrent reviews are completed upon hospital admission and every two days.
• Participates in InterQual and/or MCG competency testing.
• Completes assignments timely and communicates to appropriate care team members.
• Able to prioritize tasks, assignments, and duties under the direction of the ambulatory care management nurse.
• Notifies the ambulatory care management nurse timely when unable to complete assigned tasks or for the escalation of clinical issues or support.
• Assists the ambulatory care management nurse with duties and/or tasks as assigned.
• Performs other duties as assigned.

Requirements

• High school diploma or equivalent.
• 3 years of clinical experience.
• Experience with computer data entry.
• Typing speed of 40-55 WPM.
• Good organizational skills.
• Good customer service skills.

Preferred Qualifications

• 2 years of experience in an HMO/IPA/Managed care setting is preferred and recommended.
• 1 year of care coordination experience within the last three years preferred.
• Office skills.

Required Licenses/Certifications

• Fire Life Safety Training (LA City) – if no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date (required within LA City only).

Pay

The hourly rate range for this position is $29.00 - $45.20. When extending an offer of employment, the University of Southern California considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate’s work experience, education/training, key skills, internal peer equity, federal, state, and local laws, contractual stipulations, grant funding, as well as external market and organizational considerations.