The Patient Discharge Specialist assists the Patient Care Facilitator or designee on units without a Patient Care Facilitator by implementing the arrangements required for patients who will be discharged or transferred from the hospital to an extended care facility, home, or another appropriate level of care.  The Patient Discharge Specialist provides logistical support for the discharge care plan, including:  verifying insurance benefits for coverage of post-discharge needs; communicating with patient/family for elicitation of choice and providing education as to available options; completing required documentation and disseminating it to community service providers and payors; coordinating discharge/admission hand-offs and transportation needs; and coordinating recommended post-discharge equipment needs.

Licensure/Certification/Registry: (preferred not required):

• Valid state license to practice practical nursing (LPN).

Experience:

• Minimum of two years of acute care or long term care experience.

Other Knowledge/Skills/Abilities:

• Understanding of healthcare reimbursement mechanisms required.
• Strong oral and written communication skills required.
• Customer service experience and/or training preferred.
• Office computer skills required.

1. Discharge Coordination:

• Communicates daily with Patient Care Facilitator or Social Work staff on units without a Patient Care Facilitator to coordinate arrangements outlined in patient discharge plans. Be able to problem-solve and discuss options for complex patients with multiple discharge needs.

• Interacts with patients and/or families to discuss discharge preferences, including options for extended care facilities for short- or long-term placements, elicit choice of facilities. Referrals sent to facilities for review, updated communication of new needs/care, coordination of transfer to facility.

• Interacts with patients and /or families to discuss discharge preferences, including options of home health services for home services when appropriate, elicit choice of home health agency. Referrals to agencies for review, updated communication of new needs/care, coordination of home health agency’s first visit to patient’s home.

• Confirm patient’s status at nursing facility if a nursing home resident and provide regular updates on the patient’s condition and new needs, coordinate transfer back to nursing facility.

• Confirm patient’s status with home health agency if receiving home health services and provide regular updates on the patient’s condition and new needs, coordinate first home health visit once patient returns home.

• Arrange for appropriate transportation mode for patient if needed and complete Physician Certification Statement for ambulance transports.

• Referral to State agencies for compliance with nursing home prescreens and criminal background checks.

• Compile face-to-face documentation for Medicare/Medicaid coverage of discharge services, such as home health services; send documentation to home health agency.

• Presents final discharge plan to patient/family and obtains signature(s) on the Discharge Worksheet indicating agreement.

• Processes patient applications, forms, etc. required for discharge services and copies of medical record.

• Completes phone contacts with potential community providers of needed services, ensuring timely follow up and closure on issues required for patient discharge.

• Completes calls to insurance carriers to verify benefits or obtain in-network list of in-network providers and complete appropriate documentation.

• Coordinates referrals to community skilled facilities or agencies to ensure the safe delivery of post-discharge services to patients.

• Obtains appropriate signature on final Medicare Important Message forms.

2. Utilization Management Department Support:

• Completes data collection as requested to meet departmental objectives and for work groups reviewing work processes.

• Performs follow up phone calls on patients/families with changes in discharge plans that occurred after discharge, or to follow up on identified issues that occurred prior to discharge. Complete appropriate documentation in patient record.

• Maintains solid working relationships with regional agencies, hospitals, and providers of needed services.

• Adheres to Statement of Values and Behavioral Standards.

• Participates in continuing education and in-service training to support professional growth and maintain expertise in discharge coordination function.

• Assists in the development of programs, policies, and procedures which support and guide the provision of services by the discharge specialist team.

3. Participates in departmental on-call and weekend coverage schedule.