Discharge Planning Coordinator, LVN - Case Management - Per Diem 8 Hour Rotating
Keck Medicine of USC, Los Angeles, CA, United States
Provides department support for the Continuum of Care Team to facilitate discharge planning and ensure appropriate throughput of patients. Works with Case Managers, Transitional Care Coordinator, and Social Workers to ensure discharge plans are communicated to patients and families during hospitalization and post discharge to ensure continuity and identify clinical barriers. Enables a positive patient experience through the discharge process and connection to resources as needed.
Essential Duties
Partners with members of the Continuum of Care team, including case managers and social workers, to provide patients and family members a smooth, coordinated transition from hospital to home and/or next level of care.
Partners with the Care Coordination team to ensure appropriate communication occurs at the point of discharge so that the patients’ transition is smooth; provides timely post‑acute contact and reinforces post‑discharge instructions as needed under the direction of the Transitional Care Coordinator.
Under the direction and supervision of the Transitional Care Coordinator, utilizes multiple referral platforms such as Enso Care, e‑fax, and phone calls to review post‑acute referrals, discharge instructions, and summary to understand patients’ post‑acute plan of care and barriers to follow‑up; provides timely follow‑up on all referrals.
Participates in post‑discharge phone calls to patients, using scripts and following the Cipher Health algorithm for communication with discharged patients.
Communicates frequently and directly with clinic physician staff and other post‑acute providers as needed for discharged patients with identified needs.
Follows established policies and procedures and workflows regarding post‑discharge phone calls.
Communicates the discharge plan and status of plan to members of the Continuum of Care team, including allied health care team members; participates in triad huddles and in the provisioning of assignments of the triad team.
Contacts post‑acute care facilities as directed to assess bed availability, submission of referrals, and bed‑hold days, utilizing multiple referral platforms such as faxing and Enso Care to facilitate referrals.
Coordinates all non‑clinical aspects of the discharge planning process as assigned (e.g., durable medical equipment, homeless shelters, non‑clinical letters, transportation) and reports any psychosocial needs, barriers or challenges to the appropriate Continuum of Care team member.
Communicates frequently and directly with Continuum of Care team members regarding discharge process needs and priorities; communicates orders received to the appropriate case manager; works with the Triad team for daily assignments and tasks needing to be completed; hands off tasks and duties not performed.
Participates in departmental meetings, including staff meetings, daily huddles, triad huddles, and Continuum of Care team meetings.
Utilizes tools such as Medicare.gov, tablets for patient choice, etc., as needed to provide patients with skilled nursing facilities and/or information on discharge planning resources within 10 miles or as close to the patient’s home as possible.
Documents appropriately following departmental standards in the electronic Medical Record.
Assists with transfer of patients for lateral and/or acute services.
Supports the Continuum of Care team with arranging transportation using Taxi, Ride Share, ambulance, etc.
Assists with maintaining and updating current resources (e.g., pamphlets and brochures) for services as needed for post‑acute care for use by the care coordination team.
Participates and engages in continuous improvement activities, including huddles and process improvement projects.
Follows all departmental standard work and guidelines including the Triad Model of Discharge Planning; supports transitions of care.
Develops and maintains positive working relationships with outside post‑acute facilities and vendors to promote timely discharge/transfer.
Thrives in a fast‑paced, multi‑faceted team environment, working well with key stakeholders, meeting tight deadlines, and multitasking a variety of assignments.
Strives to support and contribute to the success of the Continuum of Care team’s outcome metrics, key performance indicators, and/or departmental goals and objectives.
Represents the department in a positive and professional manner.
Floating between assignments and between Keck and Norris hospitals is required for management of department needs; on‑call, weekend coverage and rotation to manage the discharge needs of patients within the organization is expected.
Supports the clinical process for transfer from one level of care to another as medically indicated by the patient’s needs; applies clinical knowledge to reference InterQual Discharge Screens and clinical stability for discharge/transition to the next appropriate level of care.
Completes clinical authorization process for the discharge medication.
Performs other duties as requested/assigned by Director.
Required Qualifications
High school diploma or equivalent.
Completed an accredited vocational nursing program.
Two to three years of clinical experience.
Typing speed of 40‑55 words per minute; experience with computer data entry.
Proficient in Microsoft Office Suite.
Good organizational skills.
Strong command of the English language.
Good customer service skills.
Ability to multitask and work effectively in a team environment.
Required Licenses/Certifications
Licensed Vocational Nurse – LVN (CA DCA).
Fire Life Safety Training (LA City). If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date (required within LA City only).
The hourly rate range for this position is $28.00 – $47.75. When extending an offer of employment, the University of Southern California considers factors such as the scope and responsibilities of the position, the candidate’s work experience, education/training, key skills, internal peer equity, federal, state, and local laws, contractual stipulations, grant funding, as well as external market and organizational considerations.
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Essential Duties
Partners with members of the Continuum of Care team, including case managers and social workers, to provide patients and family members a smooth, coordinated transition from hospital to home and/or next level of care.
Partners with the Care Coordination team to ensure appropriate communication occurs at the point of discharge so that the patients’ transition is smooth; provides timely post‑acute contact and reinforces post‑discharge instructions as needed under the direction of the Transitional Care Coordinator.
Under the direction and supervision of the Transitional Care Coordinator, utilizes multiple referral platforms such as Enso Care, e‑fax, and phone calls to review post‑acute referrals, discharge instructions, and summary to understand patients’ post‑acute plan of care and barriers to follow‑up; provides timely follow‑up on all referrals.
Participates in post‑discharge phone calls to patients, using scripts and following the Cipher Health algorithm for communication with discharged patients.
Communicates frequently and directly with clinic physician staff and other post‑acute providers as needed for discharged patients with identified needs.
Follows established policies and procedures and workflows regarding post‑discharge phone calls.
Communicates the discharge plan and status of plan to members of the Continuum of Care team, including allied health care team members; participates in triad huddles and in the provisioning of assignments of the triad team.
Contacts post‑acute care facilities as directed to assess bed availability, submission of referrals, and bed‑hold days, utilizing multiple referral platforms such as faxing and Enso Care to facilitate referrals.
Coordinates all non‑clinical aspects of the discharge planning process as assigned (e.g., durable medical equipment, homeless shelters, non‑clinical letters, transportation) and reports any psychosocial needs, barriers or challenges to the appropriate Continuum of Care team member.
Communicates frequently and directly with Continuum of Care team members regarding discharge process needs and priorities; communicates orders received to the appropriate case manager; works with the Triad team for daily assignments and tasks needing to be completed; hands off tasks and duties not performed.
Participates in departmental meetings, including staff meetings, daily huddles, triad huddles, and Continuum of Care team meetings.
Utilizes tools such as Medicare.gov, tablets for patient choice, etc., as needed to provide patients with skilled nursing facilities and/or information on discharge planning resources within 10 miles or as close to the patient’s home as possible.
Documents appropriately following departmental standards in the electronic Medical Record.
Assists with transfer of patients for lateral and/or acute services.
Supports the Continuum of Care team with arranging transportation using Taxi, Ride Share, ambulance, etc.
Assists with maintaining and updating current resources (e.g., pamphlets and brochures) for services as needed for post‑acute care for use by the care coordination team.
Participates and engages in continuous improvement activities, including huddles and process improvement projects.
Follows all departmental standard work and guidelines including the Triad Model of Discharge Planning; supports transitions of care.
Develops and maintains positive working relationships with outside post‑acute facilities and vendors to promote timely discharge/transfer.
Thrives in a fast‑paced, multi‑faceted team environment, working well with key stakeholders, meeting tight deadlines, and multitasking a variety of assignments.
Strives to support and contribute to the success of the Continuum of Care team’s outcome metrics, key performance indicators, and/or departmental goals and objectives.
Represents the department in a positive and professional manner.
Floating between assignments and between Keck and Norris hospitals is required for management of department needs; on‑call, weekend coverage and rotation to manage the discharge needs of patients within the organization is expected.
Supports the clinical process for transfer from one level of care to another as medically indicated by the patient’s needs; applies clinical knowledge to reference InterQual Discharge Screens and clinical stability for discharge/transition to the next appropriate level of care.
Completes clinical authorization process for the discharge medication.
Performs other duties as requested/assigned by Director.
Required Qualifications
High school diploma or equivalent.
Completed an accredited vocational nursing program.
Two to three years of clinical experience.
Typing speed of 40‑55 words per minute; experience with computer data entry.
Proficient in Microsoft Office Suite.
Good organizational skills.
Strong command of the English language.
Good customer service skills.
Ability to multitask and work effectively in a team environment.
Required Licenses/Certifications
Licensed Vocational Nurse – LVN (CA DCA).
Fire Life Safety Training (LA City). If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date (required within LA City only).
The hourly rate range for this position is $28.00 – $47.75. When extending an offer of employment, the University of Southern California considers factors such as the scope and responsibilities of the position, the candidate’s work experience, education/training, key skills, internal peer equity, federal, state, and local laws, contractual stipulations, grant funding, as well as external market and organizational considerations.
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