Job Description

Provides department support for the Continuum of Care Team to facilitate discharge planning and ensure appropriate throughput of patients. Works with Case Managers, Transitional Care Coordinator, and Social Workers to ensure discharge plans are communicated to patients and families during hospitalization and post discharge to ensure continuity and identify clinical barriers. Enables a positive patient experience through the discharge process and connection to resources as needed.
Essential Duties: \xe2\x80\xa2 Partners with members of the Continuum of Care team both case managers and social workers (RN Case Manager, SW Case Manager) in an effort to provide patients and family members a smooth, coordinated patient transition from hospital to home and/or the next level of care. \xe2\x80\xa2 Partners with members of the Care Coordination team to ensure appropriate communication occurs at the point of discharge so that the patients\xe2\x80\x99 transition is smooth. Provides timely post-acute contact and reinforces post discharge instructions as needed under the direction of the Transitional Care Coordinator. \xe2\x80\xa2 Under the direction and supervision of Transitional Care Coordinator, utilizes multiple referral platforms such as Enso care, e-fax and phone calls etc. to review post-acute referrals. Also reviews discharge instructions and discharge summary to understand patients\xe2\x80\x99 post-acute plan of care and barriers to follow-up. Provides timely follow-up on all referrals. \xe2\x80\xa2 Under the direction and supervision of the Transitional Care Coordinator, participates in post discharge phone calls to patients. Uses scripts and follows the Cipher Health algorithm for communication with discharged patients. \xe2\x80\xa2 Under the direction and supervision of the Transitional Care Coordinator, communicates frequently and directly with clinic physician staff and other post-acute providers as needed for discharged patients with identified needs. \xe2\x80\xa2 Follows established policies and procedures and workflows regarding post discharge phone calls. \xe2\x80\xa2 Communicates the discharge plan, status of plan to members of the Continuum of Careteam, including allied health care team members. Participates in triad huddles and in the provisioning of assignments of the triad team. \xe2\x80\xa2 Contacts post-acute care facilities as directed by the Continuum of Careteam to assess bed availability, submission of referrals, bed-hold days. Utilizes multiple referral platforms such as faxing, Enso care etc. to facilitate referrals. \xe2\x80\xa2 Coordinates all non-clinical aspects of the discharge planning process as assigned (i.e. durable medical equipment, homeless shelters, non-clinical letters, transportation) reporting any psychosocial needs, barriers or challenges to the appropriate Continuum of Careteam member. \xe2\x80\xa2 Communicates frequently and directly with Continuum of Care team members regarding discharge process needs and priorities. Communicates orders received to the appropriate case manager, works with the Triad team for daily assignments and tasks needing to be completed. Hands off tasks and duties not performed. \xe2\x80\xa2 Participates in departmental meetings, including but not limited to staff meetings, daily huddles, triad huddles, and Continuum of Care team meetings, etc. \xe2\x80\xa2 Utilizes tools (i.e. Medicare.gov website, tablets for patient choice, etc.) as needed to provide patients with skilled nursing facilities and/or information on discharge planning resources within 10 miles or as close to the patient\xe2\x80\x99s home as possible. \xe2\x80\xa2 Documents appropriately following departmental standards in the electronic Medical Record. \xe2\x80\xa2 Assists with transfer of patients for lateral and/or acute services. \xe2\x80\xa2 Supports the Continuum of Careteam with arranging transportation using Taxi, Ride Share, ambulance etc. \xe2\x80\xa2 Assists with maintaining and updating current resources (i.e. pamphlets and brochures) for services as needed for post acute care for use by care coordination team. \xe2\x80\xa2 Participates and engages in continuous improvement activities, including huddles and process improvement projects. \xe2\x80\xa2 Follow all departmental standard work and guidelines including the Triad Model of Discharge Planning. Support transitions of care. \xe2\x80\xa2 Develops and maintains positive working relationships with outside post-acute facilities and vendors to promote timely discharge/transfer. \xe2\x80\xa2 Thrives in a fast-paced, multi-faceted team environment, working well with the key stakeholders, meeting tight deadlines, and multitasking a variety of assignments. \xe2\x80\xa2 Strives to support and contribute to the success of the Continuum of Care team\xe2\x80\x99s outcome metrics, key performance indicators and /or departmental goals and objectives. \xe2\x80\xa2 Represents the department in a positive and professional manner. \xe2\x80\xa2 Floating between assignments and between Keck and Norris hospitals is required for management of department needs. On-call, weekend coverage and rotation to manage the discharge needs of the patients within the organization is expected. \xe2\x80\xa2 Supports the clinical process for transfer from one level of care to another as medically indicated by the patient\xe2\x80\x99s needs. Able to apply clinical knowledge to reference InterQual Discharge Screens and clinical stability for discharge/transition to the next appropriate level of care. \xe2\x80\xa2 Completes clinical authorization process for the discharge medications. \xe2\x80\xa2 Performs other duties as requested/assigned by Director. Qualifications: \xe2\x80\xa2 Req High school or equivalent \xe2\x80\xa2 Req Specialized/technical training Nursing Completion of an accredited vocational nursing program. \xe2\x80\xa2 Req 2 years 2-3 years\xe2\x80\x99 clinical experience. \xe2\x80\xa2 Req Typing 40-55 WPM. Experience with computer data entry. \xe2\x80\xa2 Req Proficient in Microsoft Office Suite. \xe2\x80\xa2 Req Good organizational skills. \xe2\x80\xa2 Req Strong command of the English language. \xe2\x80\xa2 Req Good customer service skills. \xe2\x80\xa2 Req Ability to multitask and work effectively in a team environment. Required Certifications: \xe2\x80\xa2 Req Licensed Vocational Nurse - LVN (CA DCA) \xe2\x80\xa2 Req 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) The hourly rate range for this position is $28.00 - $47.75. 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\xe2\x80\x99s 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.