Discharge Case Manager

The Transitional Case Managers(TCM) primary responsibility is to facilitate a seamless transition for patients discharging from a facility setting to the care of an LHC Group agency for post-acute care needs. Included and aligned within this responsibility is the understanding and implementation of company market development initiatives and their role in growth as we focus on serving more patients and delivering exceptional care. The TCM will verify home health orders, assess the care required, and ensure continuity of care and the agency's ability to meet the needs of the patient. This clinical liaison position will assess each patient to determine their level of health literacy and be adept at ensuring the patients and families are included in care planning. Following identification of needs the TCM will begin best practice intervention and education to improve patient outcomes and promote patient self-management. The TCM will implement rehospitalization reduction initiatives for patients with Acute Care Hospitalization risk and continually communicate between healthcare providers during all phases of transition from the facility into the home. Identifies primary care physician to follow the plan of care

• Educates patient on importance of the post facility discharge follow up appointment with the physician
• Assess patient's risk for readmission using LACE tool and documents in Transition encounter
  Educates patient on homebound criteria and verifies patient meets these requirements
• Educates LHC Group referrals on Call First process and ensures patient and family have agency contact information
• Educates patient on obtaining all necessary prescriptions prior to discharge from hospital and confirms patient's understanding of medication, pharmacy, and delivery method
• Coordinates other ancillary services for the patient (DME| Infusion) as needed
• Assists the LHC Group agency in preparation of accepting care of the patient post discharge
• Serves as a liaison between the LHC Group agency and all involved healthcare providers of newly referred patients as well as existing patients transferred to the hospital from the home health agency
• Communicates to discharge planning any active patients that transfer from home health into a Facility and coordinates resumption of care with patient prior to discharge if applicable orders are obtained
• Provides follow up feedback to case management team regarding status of readmissions and any non-admit decisions based on information provided to them by the LHC agency
• All other duties as assigned

Experience Requirements

• Must have one year home health experience or one year of hospital case management experience.

License Requirements

• Must have current RN or LPN or SW licensure in state of practice
• Reliable means of transportation and must have current driver's license and auto insurance

Skill Requirements

• Must have excellent verbal and written communication skills with all members of the healthcare team
• Must have excellent organizational skills and ability to complete competing priorities
• Must have thorough understanding of home health qualifying criteria and coverage guidelines
• Proficient computer skills.