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Job Description:
Position Summary
Under the leadership of the Director and Assistant Director of Post-Acute Services, the Case Manager Specialist provides administrative and logistical coordination support for discharge planning and transition-of-care activities for patients and residents served by the Inpatient Rehabilitation Unit (IRU) and Westland House. The position works with patients, families, the interdisciplinary team, providers, payers, and community partners to identify discharge needs, address barriers, coordinate services and equipment, and support safe, timely transitions to the next level of care. The Case Manager Specialist provides administrative and coordination support.
Essential Duties and Responsibilities
Discharge Planning and Transition Coordination
· Initiate and maintain the administrative workflow supporting discharge-planning for assigned patients and residents, using information, recommendations and direction provided by licensed clinicians and the interdisciplinary team.
· Gather information from patients, families, significant others, providers, and the care team regarding living situation, available support, transportation, equipment, follow-up services, and potential barriers to discharge and communicate concerns to the interdisciplinary team.
· Coordinate administrative discharge arrangements for home, community-based services, outpatient therapy, home health, skilled nursing, long-term care, assisted living, or other settings as directed by the interdisciplinary plan of care.
· Track target discharge dates, required tasks, referrals, authorizations, appointments, and outstanding barriers; escalate delays or concerns to the appropriate licensed clinician or leader.
· Provide administrative support for transfers and discharges, including communication with receiving providers and confirmation that required arrangements are completed.
Interdisciplinary Collaboration
· Participate in IRU Patient Care Conferences, Westland House care conferences, discharge huddles, and other interdisciplinary meetings; communicate the status of discharge arrangements and identified barriers.
· Partner with nursing, therapy, physicians, social services, admissions, utilization management, pharmacy, and other disciplines to support an organized transition plan.
· Serve as a consistent point of contact for routine administrative coordination related to discharge and transitions of care among patients, families, the care team, and external agencies.
· Refer clinical questions, changes in condition, medical decision-making, and scope-restricted activities to the appropriate licensed professional.
Patient and Family Support
· Explain the discharge-planning process, services identified by the interdisciplinary team, and required next steps in a clear, respectful, and service-oriented manner.
· Coordinate patient and caregiver meetings, observations, training sessions, and follow-up communication as requested by the clinical team.
· Provide information about community resources, transportation, caregiver support, financial assistance programs, and insurance-related processes within the scope of the position.
· Document communications, preferences, barriers, and follow-up activities in the electronic medical record according to department standards.
Resource, Referral, and Equipment Coordination
· Process and track referrals for post-discharge services, including outpatient therapy, home health, durable medical equipment, transportation, and community programs, based on orders and recommendations from authorized clinicians.
· Communicate with vendors, facilities, insurers, and community providers to obtain information, confirm availability, and support timely service delivery.
· Assist with insurance verification, authorization follow-up, and…