Applies and shares knowledge of community health and social service
Evaluates medical information and completes discharge needs
assessments within 1 day of admission as set by established
criteria, to identify patients that are at high risk of requiring
post-hospital services, and the need for case management and
discharge planning intervention.
Initiate and complete safe discharge plans for inpatients by
arranging Home Health referrals, complex drug therapy
interventions, outpatient clinic visits, skilled nursing
placements, intermediate care placements, assisted living
Documents initial assessment of the patient and continually
assesses discharge needs through the continuum of care.
Works closely with external vendor partners to arrange
post-discharge needs, maintains amiable and professional
relationship with vendors at all times.
Assesses variables that impact health and functioning, interprets
clinical information and assesses implications for
Issues Important Messages from Medicare (IMM), Medicare Outpatient
Observation Notice (MOON), and denial of services letter following
appropriate health plan or Medicare guidelines.
Collaborates with Hospitalists and Multi-Disciplinary team daily to
facilitate the timely discharge of patients from the hospital
Enters Avoidable Days and Code 44 Documentation when
Provides information to patients and families on “Advanced
Directives” when requested.
Responds to outpatient and community questions and
Screens patient’s medical records concurrently and/or
retrospectively using pre-established screening criteria for
quality assurance and discharge planning.
Facilitates discharge planning for the continuum of
Facilitates placements or referrals as appropriate to meet the
patient’s clinical needs/rights and are specific for neonate,
infant, pediatric, adolescent, adult and geriatric
Reports suspected abuse, neglect, or unsafe discharge environment
to the appropriate agency.
Develops an individualized case management plan that addresses
physical, vocational, psychosocial, age, cultural, financial and
educational needs and documents case management
Coordinates the appropriate services and resources
Communicates with patient/family/significant others and all
multi-disciplinary team members for appropriate post-hospital
Consults with the social worker to identify appropriate social
Provides insurance carriers with necessary information to authorize
follow-up care when necessary and obtains pre-authorization for
post-discharge services including Skilled Nursing, Durable Medical
Equipment, Home Oxygen, or Rehabilitation.
Relays pertinent information to the Case Management Manager to
represent Case Management with internal medical or quality
committees, inpatient nursing staff, ancillary provider staff as