- Initiates and assures appropriate sequencing of care / interventions for optimal results through the care continuum with consideration for financial risk populations (i.e. Bundles, Medicare Shared Savings Plan (MSSP), Medicaid ACO, Service Line Programs (Spine/Ortho)).
- Uses independent judgment to direct team members around patient care progression. Identifies barriers to safe discharge, assigning clear accountability for each follow-up and barrier and recording the assignment to keep everything organized. Presents outcomes at huddle.
- Challenges decisions or barriers that will result in a patient not meeting their LOS Target, seeking alternatives to keep the patient on track. Escalates any potential outliers identified at 48 and 24 hours prior to target discharge date.
- Holds team members accountable to the patient care progression process.
- Coordinates simple discharge planning, i.e. DME, VNA, transportation. Coordinates discharge plan related to patient needs and payer requests.
- Current Massachusetts registered nursing license or Massachusetts licensed independent clinical social worker (LICSW).
- Baccalaureate degree in nursing, business and other care related field or master’s degree in social work (MSW).
- Minimum of 3-5 years of direct acute clinical experience.
- Knowledge of discharge planning, risks contracts, value based care, and total medical experience.
- Ability to analyze clinical, financial and social solutions, identifying problems and alternative courses of action.
- Flexible, resourceful and creative in problem solving.
- Proven prioritization skills.
- Ability to act independently and present information clearly and concisely.
- Excellent interpersonal skills with all internal and external stakeholders.
- Previous supervisory experience.
- Clinical expertise in specialty area.
- Master’s degree in nursing, social work, business or other care related field.
Location: Lawrence General Hospital · Nursing Support
Schedule: 40 hours, Days