Job Description

Primary Responsibilities:

• To oversee and coordinate each patient's hospital stay beginning with admission through discharge.
• Work with all members of the interdisciplinary care team to identify goals, address barriers to discharge and ensure patient receives the optimum rehabilitation services in the most efficient manner.
• Provide the patient and family information about the rehabilitation process, levels of care, and patient rights/responsibilities.
• Work within the confines of CMS guidelines and/or Managed Care expectations, able to advocate for patients when possible.
• Ensure patient is provided with appropriate resources befitting next level of care setting (e.g., list of skilled nurse facilities, available home health agencies, etc.).
• Maintain appropriate patient and family contact regarding patient progress towards goals, care team discussions, as well as continual review of discharge planning efforts to ensure a safe and timely discharge plan is in place.
• Address disposition changes in timely manner, remaining proactive in anticipating patient's discharge needs.

Prerequisites:

• Registered Nurse with 2-5 years acute care case management experience.
• Excellent communication (written and verbal), interpersonal and organizational skills.
• Ability to assess, analyze, plan, implement and evaluate plan of care.
• Basic knowledge of CMS guidelines, Managed Care products, and criteria for inpatient rehab vs. long-term acute hospital admission.

Benefits:

• 401(k)
• Paid Sick Time

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