JOB ACCOUNTABILITIES

+ Completes initial discharge plan, per CMS Conditions of Participation, provides appropriate level of intervention and makes referrals as necessary. The initial discharge plan must be co-signed by an RN Case Manager or LCSW.

+ When completing the initial discharge plans, reviews the psychosocial situation and discharge planning resources as requested, and provides information to Case Managers, Social Workers, and healthcare team.

+ Collaborates with community resources, agencies, and facilities to provide smooth transition of care from hospital to community, ensuring that arrangements are made in a timely, cost-effective manner.

+ Monitors patient progress against discharge plan in collaboration with Case Managers and other healthcare team members.

+ Works collaboratively with Case Managers, Social Workers, Resource Specialists, and staff nurses to complete discharge planning.

+ Works closely with patients and ...