Continuum Coordinator (C2) Discharge Planner

NY_SJHSYR10 St. Joseph's Hospital Health Center; United States; On-site; USD 33,000 - 43,000; Full time

Job summary

Trinity Health Corp. in the United States seeks a Continuum Coordinator (C2) Discharge Planner to collaborate with the Clinical Care Manager, physicians and care team to guide patient progression and transition to post-acute settings.

You will engage patients and families, coordinate referrals to home care, DME, rehab, ensure prior authorization, document transitions, and advocate for timely, appropriate care across the continuum.

Qualifications

• Associate's degree in health-related field is required or preferred.
• Three years of experience in a health-related field are required.
• Working knowledge of discharge planning and community resources is preferred.

Responsibilities

• Discharge planning: actively engages patient and family during discharge and provides resources on options, costs, and services.
• Facilitates referrals to home care agencies, rehabs, DME vendors, home infusion vendors, and other programs.
• Assists with insurance preauthorization/post-acute care service approvals.
• Documents the transitional plan of care and communicates with care team.
• Escalates patient quality concerns to the Clinical Care Manager and participates in quality reviews.

Skills

Discharge planning

Care coordination

Patient advocacy

Interdisciplinary teamwork

Education

Associate's degree in health-related field

Job description

Employment Type: Full time Shift: Day Shift Description: Hours 7-3:30 Monday-Friday weekend rotation every 12th week.

The Continuum Coordinator (C2) Discharge Planner assists with collaboratively managing the progression of patient’s care with the Clinical Care Manager, physician and health care team utilizing evidence based best practice guidelines, The C2 Discharge Planner engages the patient and care team in the joint management of key patient outcomes and transition to most appropriate post- acute setting. The C2 – Discharge Planner is a patient advocate who is focused on the whole patient experience not just the acute care episode, Ensures optimal communication and management of patient flow across the continuum. The C2-Dischage Planner serves as a resource to the staff, patients, and families. Staff member in this position work within and contribute to an environment where our Mission is actualized, patient focused outcomes are achieved, and high-quality practice is realized.

Primary Duties

• Discharge Planning: Actively engages patient and family during the discharge process and provides ed resources regarding choice, cost and scope of services provided, i.e., Dialysis, Pharmaceutical, home infusion under the direction of senior staff.
• Facilitates referrals to home care agencies, rehabs, DME vendors, home infusion vendors and home lab, or other programs as directed by the Clinical Care Manager.
• Assists with prior approval/ preauthorization from insurance for post acute care services.
• Proactively identifies and removes barriers by providing information and referral services/linkages to entitlement programs, insurance programs or other appropriate hospital resources as well as community-based organizations.
• Explains to patient/family the Medicare important notice, their appeal rights and 3-day qualifying hospital stay requirements for Sub Acute Rehabilitation coverage services if appropriate.
• Facilitates patient transfers to other healthcare organizations in accordance with hospital policies and all applicable State and Federal guidelines/ regulations and Joint Commission standards.
• Documents all information pertinent to the transitional plan of care.
• Provide information to patient/family regarding discharge planning, length of stay, appropriate use of health care resources and the appeal process.
• Makes timely referrals to appropriate community services based on identified needs that assures continuity of care through the progression of patient’s plan of care.
• Cleary documents discharge plan and provides appropriate information to post hospital care providers.
• Quality Improvement: Advocates for culturally competent care and appropriate literacy level.
• Escalates any patient quality concerns to Clinical Care Manager or unit leadership and attends Patient Safety & Quality reviews as needed.
• Reports all variances through established outcome management and quality improvement process.
• Verifies patient identification prior to discharge handoff to external providers.
• Identifies any avoidable days that contributed to increased length of stay and documents appropriately.
• Utilizes the teach back process to ensure patients/families are informed regarding their discharge plan.
• Patient Flow /Progression of Care: Identifies variances in care reasons and escalates Clinical Care Manager or local leadership.
• Assures timely progression to appropriate levels of care.
• Consistently advocates for care in the right setting and at the right level.
• Ensure arrangements for discharge are timely to facilitate patient flow.
• Leadership: Serves as a role model in an ever-changing environment which supports the hospital mission.
• Participates in unit-based interdisciplinary meetings in a patient centric manner.
• Develops and mentors C2 Discharge Planning Staff as necessary.
• Fosters team’s ability to work together and achieve desired outcomes.
• Recognize the strength and expertise of all members to develop and implement the most patient centric plan.

Minimum Qualifications

• Associate's degree in health-related field
• Three years of experience in health-related field
• Working knowledge of discharge planning and community resources preferred

Mission Statement

We, St Joseph’s Health and Trinity Health, serve together in the spirit of the Gospel as a compassionate and transforming healing presence within our communities.

Vision

To be world-renowned for passionate patient care and outstanding clinical outcomes.

Core Values

• In the spirit of good Stewardship, we heal by practicing Justice in fostering right relationships to promote common good
• Reverence in honoring the dignity of every person
• Excellence in expecting the best of ourselves and others
• Integrity in being faithful to who we say we are

Pay Range

Pay Range: $23.80 - $31.40 Pay is based on experience, skills, and education. Exempt positions under the Fair Labor Standards Act (FLSA) will be paid within the base salary equivalent of the stated hourly rates. The pay range may also vary within the stated range based on location

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care.

Equal Opportunity

We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

About Trinity Health

Trinity Health is one of the largest not-for-profit, faith-based health care systems in the nation. Together, we’re 121,000 colleagues and nearly 36,500 physicians and clinicians caring for diverse communities across 27 states. Nationally recognized for care and experience, our system includes 101 hospitals, 126 continuing care locations, the second largest PACE program in the country, 136 urgent care locations, and many other health and well-being services. Based in Livonia, Michigan, in fiscal year 2023, we invested $1.5 billion in our communities through charity care and other community benefit programs. For more information, visit http://www.trinity-health.org. You can also follow Trinity Health on LinkedIn.