Collaborates with the bedside nurse and clinical team, meets with patient and or family to complete an initial discharge planning assessment within 24 hours of patient admission. Identifies patients and families with complex psychosocial, financial and legal discharge planning needs requiring a Social Work referral. Develops, documents and implements a discharge plan consistent with individual patient needs and with patient and family goals. Develops plans with attention to individual patient and family goals. Discusses estimated length of stay, treatment plan and discharge plan with attending physician and or medical team. Ensures that the Interdisciplinary Care Plan and Discharge Plan are consistent with patient clinical course, continued care needs and covered services. Refers to appropriate alternate site agency based on post discharge needs and patient choice. Provides linkage to community resources and UH network services to facilitate optimal care, and serves as liaison to community agencies. Communicates and collaborates with the work team using a multidisciplinary approach. Provides guidance and consultation to peers and team regarding complex psychosocial and or discharge planning issues or barriers. Participates in Interdisciplinary Team rounding. Coordinates discharge teaching. Collaborates with bedside nurse and members of Interdisciplinary Team to support teaching efforts, with special attention to situations where patient and family education requiring teach back and show back are required. Collaborates with Case Management or Utilization Review to clarify patient status, plan of care, barriers to discharge and discharge readiness.Ensures timely completion of discharge, transfer and or referral forms and discharge order. Coordinates activities to ensure patient appeal rights under Notification of Hospital Discharge Appeal Rights.

This position is located at Seidman Cancer Center and is full-time, 40 hours per week on day shift.

Experience & Knowledge:

1-5 years clinical nursing experience (acute care), required.

2 years of experience in case management/discharge planning in an acute care setting, preferred

Sound clinical knowledge base, required

Experience and knowledge of utilization management, case management, post-acute transitions, and home health preferred

Knowledge of Medicare, Medicaid and commercial payer regulations, preferred

Education:

Graduate of an accredited school of nursing, required

Bachelor’s degree, preferred

Required Credentials, License, and / or Certifications:

RN with current valid Ohio Licensure, required

CM certification, preferred

Special Skills & Equipment Knowledge:

Computer competency

Multi-tasks and prioritizes work

Works autonomously

Communicates effectively with persons of various backgrounds (oral and written)

Maintain clinical competency regarding health care delivery/regulatory requirements.

Teaching skills

Maintains a calm, professional demeanor when dealing with internal and external contacts