Job Description

1. Discharge Planning

• Coordinate referrals to Home Health, Hospice, Skilled Nursing Facilities, Assisted Living, Private Duty Care, Meals on Wheels, Lifeline, transportation services, waiver programs, and community resources.
• Coordinate safe transitions of care.

2. Financial & Insurance Assistance

• Assist with Medicaid applications and track status.
• Complete Presumptive Medicaid eligibility and maintain certification.
• Assist with Medicaid Waiver applications.
• Provide education regarding disability benefits, SNAP, insurance concerns, and financial assistance resources.

3. Advance Care Planning

• Educate and assist with Living Wills, Durable Power of Attorney for Healthcare, Power of Attorney, Guardianship resources, and Advance Directives.
• Serve as a Notary Public as applicable.

4. Community Resource Coordination

• Maintain knowledge of local resources including housing, transportation, food, utility assistance, behavioral health, substance use treatment, disability, veteran, and aging services.
• Participate in community resource meetings and collaborate with community organizations.

5. Regulatory Responsibilities

• Maintain compliance with CMS Conditions of Participation, HIPAA, Mandatory Reporter requirements, and organizational policies.
• Complete DHS reporting, abuse reporting, and required documentation.

6. Quality Improvement

• Participate in quality improvement initiatives, audits, committees, policy development, and continuing education.
• Active participation in Cancer Committee and Tumor Board

7. Demonstrate professionalism, accountability, confidentiality, and patient advocacy.

8. Perform other duties as assigned.