Support and facilitate campus and system goals for capacity management through achieving length of stay goals, identification of avoidable delays, and other care management initiatives.
Collaborate with the acute care management team, patient and family, to establish a realistic discharge plan, while identifying and documenting potential barriers to achieve the discharge plan.
Engage in collaboration and discussion with the interdisciplinary care team when applicable.
Acts as patient advocate by negotiating for, and coordinating resources with payers, agencies and vendors during transition phases.
Accurately document all interventions in compliance with CMS Conditions of Participation and DNV NIAHO standards. Communicate effectively utilizing all available internal and external methods.
Identify and present cases to care management leadership at the campuses when barriers related to facilitation of movement through the healthcare continuum are evident and require leadership intervention.
Evaluate and ensure appropriate utilization of SNFist referrals.
Ensures proper documentation is completed for post-discharge contracts.
Ongoing evaluation and maintenance of system discharge arrangement contracts.
Reviews post-acute treatment plans to identify opportunities to facilitate smooth and safe transitions through the continuity of care and coordinate the discharge plan, ensuring effective and efficient utilization of resources.
Works in collaboration with hospital and community agencies to obtain needed services and resources for patients/families/caregivers.
Adapts quickly to changes in patient status and updates the assessment and discharge plan as the patient’s situation warrants. Stays abreast of changing healthcare trends, regulatory matters and third-party payer requirements related to discharge planning and precertification of after-care benefits.
Performs other duties as assigned by the department manager.
At AdventHealth, Extending the Healing Ministry of Christ is our mission. It calls us to be His hands and feet in helping people feel whole. Our story is one of hope — one that strives to heal and restore the body, mind and spirit. Our more than 80,000 skilled and compassionate caregivers in hospitals, physician practices, outpatient clinics, urgent care centers, skilled nursing facilities, home health agencies and hospice centers are committed to providing individualized, wholistic care.