Ensures patient receives post-acute care from high value network providers, and follow up appointments are scheduled. The Patient Care Navigator (PCN) readies the patient for discharge and ensures that all patients are provided transition to the best setting for post-acute care based on their specific needs. The PCN educates patients/families on the post-acute care plan and expectation after discharge, helps them preference their best facility or service for care after discharge, and keeps a relationship with the patient/family after discharge. Within 24 hours of admission: Receive and review patient post-acute care plan and meet with patient/family. Throughout patient stay: Educate patient/family on post-acute care plan, expectations of post-discharge realities. Coordinate discharge teaching with care team. Regularly connect with the patient interdisciplinary care team. Communicate discharge plans with Care Navigation Center. Review financial responsibility with patient/family. Tailor care to patient clinical and psychosocial needs. Post-Acute facility/service and physician referencing based on patient/family needs and goals; educates patient/family on CMS quality measures. Coordinates activities to ensure patient appeal rights under Notification of Hospital Discharge Appeal Rights. Upon discharge: Confirm discharge orders. Discuss follow-up plan with family. Appointment/follow-up scheduling. Ensure DC paperwork (prescriptions/DME/referral forms/signatures) ready for discharge. After discharge: Patient follow-up call within 24 hours, continued contact based on evidence based decision tools. Medication adherence. Escalation to clinical team and post discharge issues for appropriate intervention and resolution. Effective communication skills. Understand all levels of post-acute care, hospital, and physician regulations. Ability to manage multiple processes simultaneously. Experience in transitions of care.
Ensures patient receives post-acute care from high value network providers, and follow up appointments are scheduled. The Patient Care Navigator (PCN) readies the patient for discharge and ensures that all patients are provided transition to the best setting for post-acute care based on their specific needs. The PCN educates patients/families on the post-acute care plan and expectation after discharge, helps them preference their best facility or service for care after discharge, and keeps a relationship with the patient/family after discharge. Within 24 hours of admission: Receive and review patient post-acute care plan and meet with patient/family. Throughout patient stay: Educate patient/family on post-acute care plan, expectations of post-discharge realities. Coordinate discharge teaching with care team. Regularly connect with the patient interdisciplinary care team. Communicate discharge plans with Care Navigation Center. Review financial responsibility with patient/family. Tailor care to patient clinical and psychosocial needs. Post-Acute facility/service and physician referencing based on patient/family needs and goals; educates patient/family on CMS quality measures. Coordinates activities to ensure patient appeal rights under Notification of Hospital Discharge Appeal Rights. Upon discharge: Confirm discharge orders. Discuss follow-up plan with family. Appointment/follow-up scheduling. Ensure DC paperwork (prescriptions/DME/referral forms/signatures) ready for discharge. After discharge: Patient follow-up call within 24 hours, continued contact based on evidence based decision tools. Medication adherence. Escalation to clinical team and post discharge issues for appropriate intervention and resolution. Effective communication skills. Understand all levels of post-acute care, hospital, and physician regulations. Ability to manage multiple processes simultaneously. Experience in transitions of care.
Associates Degree 2 years in clinical area required. 1 year in post acute setting preferred. Bachelor degree in relevant clinical area and or health degree preferred.