As a Care Navigator/Discharge Planner RN or SW, you will:
• Complete comprehensive psycho-social assessment and review of clinical needs of patients with focus on patient’s requirements as they transition to the next level of care
• Collaborate with physicians, nurses, social workers and other disciplines involved with care of the patient to foster a coordinated approach to discharge planning
• Identify and navigate patient testing and treatment to reduce barriers to patient discharge and preventing delays in patient care; communicates barriers to leadership for resolution and trending
• Work with high-risk population admitted to the hospital, navigating the discharge plan of care and follow up. Continues to reach out to the High-Risk Population for support and triage of patient needs
• Serve as liaison in planning care between patients, caregivers and multi-disciplinary health care providers
• Assist patients in understanding diagnosis, treatment options and resources available internal and external to the organization
• Communicate with Utilization Review staff on any denials, issues or barriers to discharge
• Identify services and resources available in the community and assists with patient connection to these services
• Participate in Interdisciplinary Rounds and other patient care conferences
• Document assessments and interventions according to departmental standards
• Communicate with Utilization Review staff on any denials, issues or barriers to discharge
• Participate in process improvement activities