Discharge Planning Navigator | Continuum Care

St. Joseph's Health; City of Syracuse (NY); On-site; USD 33,000 - 43,000; Full time

Job summary

St. Joseph's Health in Syracuse is seeking a Continuum Coordinator (C2) – Discharge Planner to manage patient transitions in collaboration with the Clinical Care Manager and care team.

The role focuses on the whole patient experience and optimizing communication across the continuum. The C2-Discharge Planner serves as a resource to staff, patients, and families, supporting evidence-based discharge planning and timely progression to appropriate post-acute settings.

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.

Responsibilities

• 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.

Skills

Discharge planning

Community resources

Patient advocacy

Education

Associate's degree in health-related field

Job description

St. Joseph's Health in Syracuse is seeking a Continuum Coordinator (C2) – Discharge Planner to manage patient transitions in collaboration with the Clinical Care Manager and care team.

The role focuses on the whole patient experience and optimizing communication across the continuum. The C2-Discharge Planner serves as a resource to staff, patients, and families, supporting evidence-based discharge planning and timely progression to appropriate post-acute settings.