Job Description
Description
Wentworth-Douglass Hospital, an affiliate of Mass General Brigham, is committed to supporting patient care, research, teaching, and service to the community. We place great value on being a diverse, equitable and inclusive organization as we aim to reflect the diversity of the patients we serve. At Mass General Brigham, we believe in equal access to quality care, employment and advancement opportunities encompassing the full spectrum of human diversity: race, gender, sexual orientation, ability, religion, ethnicity, national origin and all the other forms of human presence and expression that make us better able to provide innovative and cutting-edge healthcare and research.
Wentworth-Douglass Hospital remains among the nation’s top hospitals for patient experience as a recipient of the Healthgrades 2021 Outstanding Patient Experience Award for the eighth consecutive year. Wentworth-Douglass Hospital is renowned as one of the largest acute care hospitals in the Seacoast region of New Hampshire and Southern Maine. At Wentworth-Douglass, we value people who contribute to patient-centered care that enhances community health; we recognize and reward those who share our values and transform our patients' lives. We invite you to explore opportunities, cultivate community wellness and professional growth.
Position Overview
The Discharge Planner RN is responsible for a designated patient caseload and works with patients and the interdisciplinary care team to facilitate care transitions.
- Assess all patients for discharge needs per CMS guidelines.
- Meet directly with patient/family to assess needs and develop an individualized plan.
- Collaborate and communicate with all members of the care team to remove any barriers to care transitions.
- Discuss cases with the attending physicians.
- Ensure and maintain discharge plan consensus with patient/family, physician and payer.
- Document the discharge planning information in the medical record according to department standards.
- Seek consultation from appropriate disciplines to expedite care and facilitate discharge.
Facilitates coordination of care for patients along the healthcare continuum:
- Make all referrals for SNF, ARF, Home Services, Home IV, Enteral therapy and DME after providing patient/family with their agency options.
- Participate in multidisciplinary discharge planning rounds.
- Explore strategies to promote efficient resource utilization and timely care transitions.
- Communicate with external case managers as appropriate.
- Communicate/collaborate with all members of the health care team, including the patient, payers, & administrators, regarding the patient's needs, plan, & response.
Demonstrates professionalism in the completion of job functions within Coordination of Care:
- Collaborate with Social Work regarding long term care, hospice and guardianship.
- Coordinate team meetings/complex care huddles for medically complicated patients.
- Ensure plan of care remains patient focused.
- Ongoing collaboration with the Care Team.
- Assist medical record coders in clarification of medical clinical documentation issues.
Demonstrates excellence in leadership skills and professional performance:
- Maintain close communication with directors regarding quality of care, risk, and infection control issues.
- Facilitate/participate in ad hoc patient/family conferences designed to gather information & resolve issues related to the provision of care.
- Participate in departmental and hospital committees, ad hoc committees, task forces and work groups.
- Educate health team colleagues about case management, including the role of the case manager and the needs of the case-managed population.
- Participate in educational programs as requested &/or as appropriate.
Collect data pertinent to care management, utilization management, and performance improvement:
- Collect data related to clinical pathway variances.
- Report adverse drug reactions appropriately.
- Report issues related to infection control/surveillance.
- Document delays in transition in Midas Avoidable Denied Days entry.
Qualifications
- Experience Minimum Required: 3 years of nursing experience.
- Experience Preferred/Desired: Experience in home health nursing.
- Education Minimum Required: RN.
- Education Preferred/Desired: Bachelors Preferred; Certification in Case Management.
- Special Skills Minimum Required: Strong clinical assessment skills and knowledge of medical standards of care.
- Ability to interrelate with physicians, nurses and other hospital personnel.
- Knowledge of government, voluntary and regulatory standards, requirements and guidelines.
- Knowledge of principles related to release of information and maintenance of confidentiality of data.
- Oral and written communication skills.
- Knowledge of basic infection control practice.
- Knowledge of third party payer systems and levels of care.
- Ability to work independently.
- Strong organizational and time management skills.
EEO Statement
Wentworth-Douglass Hospital is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.
Primary Location: NH-Dover-WDH Main Hospital
Work Locations: WDH Main Hospital
789 Central Ave
Dover 03820
Job: Nursing-Other
Schedule: Standard Hours: 1
Shift: Day Job
Employee Status: Recruiting Department: WDH Care Coordination
#J-18808-Ljbffr
