Assesses member needs from the time the health plan is notified of a hospital admission, skilled nursing facility admission or an observation bed stay through the discharge or transfer to the next level of care. Identifies needs and solutions in concert with the facility staff, member and caregiver to develop a high-quality safe discharge plan. Works with the authorization and utilization management teams to generate timely requests for medical services and renders clinical determinations in accordance with healthcare policies as well as applicable state and federal regulations.

$77,200.00 - $96,500.00 Annual

What We Provide

• Referral bonus opportunities
• Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays
• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life and Disability
• Employer-matched retirement saving funds
• Personal and financial wellness programs
• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care
• Generous tuition reimbursement for qualifying degrees
• Opportunities for professional growth and career advancement
• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities

What You Will Do

• Delivers timely notification of clinical decisions that are conditions for discharge. Identifies potential barriers including, but not limited to, social needs, food/housing insecurity, and/or financial issues; links members to appropriate community resources upon discharge and follows-up as needed.
• Collaborates with management, physicians, member representatives, vendors, caregiver(s) and facility discharge planners in discharge planning coordination and transition of care; follows-up on care and medical services to ensure a high-quality safe discharge plan of care.
• Reviews the Daily Facility Census report to identify activity at assigned facilities and makes outreach to the facilities discharge planning staff to start the discharge planning process. Provides education to the discharge planning staff on the available benefits to the member.
• Participates in approval process for out-of-network services for members that receive services outside of VNS Health network services.
• Participates in weekly review rounds and interdisciplinary care team meetings conducted during a member's stay in a facility. Works with team in the development of the member's discharge plan of care.
• Conducts a Social Determinants of Health (SDOH) evaluation and makes the necessary connections to community-based providers and services as determined by the discharge plan of care.
• Identifies opportunities for alternative care options and contributes to the development of member focused plan of care to facilitate a safe discharge and transition back into the community after an observation stay, a hospitalization or a skilled nursing facility stay.
• Coordinates with the Authorization and Utilization Management teams to ensure all required authorizations are complete and transferred to the appropriate vendors to enable the execution of the discharge plan of care, including coordination of skilled care and nurse placements.
• Maintains accurate records of all discharge planning activities. Maintains written progress notes and verbal communications according to program guidelines.
• Provides education and facilitates open discussions with providers, members, and their families to better understand members' disease, diagnosis, treatment and program options available including curative treatment, palliative care, transitional concurrent care and hospice services.
• Ensures compliance with state and federal regulatory standards and VNS Health and the health plans' policies and procedures.
• Coordinates with community providers to ensure efficient and effective transitions and delivery of care in the home and community.
• Works with discharging facility to communicate the discharge plan to next level care for the discharged member.
• Works with the Care Management team to coordinate delivery of the discharge plan.
• Follows-up with member/family after discharge to check on execution of discharge plan and member/family satisfaction. Educates them on the discharge orders and medication reconciliation.
• Assists in procuring the discharge summary from the acute and sub-acute facilities and ensures this information is available in the members record in the care management system.
• Identifies and provides recommendations for improvement regarding department processes and procedures.
• Maintains current knowledge of organizational or state-wide trends that affect utilization trends and the impact that concurrent review and a high-quality plan of care for discharge has on readmissions and emergency room utilization.
• Improves clinical and cost-effective outcomes such as reduction of hospital admissions and emergency department visits through effective plan of care development for discharge and collaboration with care management, utilization management and other IDT members.
• Provides input and recommendations for design and development of processes and procedures for effective member discharge planning, collaboration with acute and subacute facilities and to deliver on excellent customer service.
• Keeps current with all health plan changes and updates through on-going training, coaching and educational materials.
• Participates in special projects and performs other duties as assigned.

Licenses and Certifications:

• Current license to practice as a Registered Professional Nurse in New York State for RNs required
• Current license to practice as a Social Worker in New York State for SWs
• required
• Certified Case Manager preferred

Education:

• Associate's Degree In Nursing required or
• Master's Degree In Social Work required
• Bachelor's Degree In Nursing preferred

Work Experience:

• Minimum two years of experience with strong case management/discharge planning background or two years acute inpatient hospital experience in discharge planning required
• Knowledge of Medicare and Medicaid regulations required
• Excellent organizational and time management skills, interpersonal skills, verbal and written communication skills required
• Working knowledge of Microsoft Excel, Power-Point, and Word required
• Experience working with community-based organizations in underserved communities required