Job Summary:

The SNF Discharge Patient Engagement Coordinator will work closely with the Patient Engagement Manager to facilitate the discharge process for short-term skilled nursing facility patients. This role is essential in establishing relationships with patients and their families, ensuring they are informed and prepared for follow-up care after discharge. The coordinator will play a key role in managing care transitions to home care services and providing education to patients about their post-discharge plans.

Key Responsibilities:

• Assist in developing relationships with patients and families to ensure a smooth transition from the SNF to home care.
• Coordinate the discharge process, including scheduling follow-up appointments and arranging home health services.
• Educate patients and families on discharge plans, including medication management and post-discharge care instructions.
• Collaborate with healthcare teams to gather and communicate necessary patient information for continuity of care.
• Identify and address any barriers that may affect a patient’s discharge or transition to home care.
• Maintain accurate and up-to-date records of patient interactions and care plans in accordance with facility policies.
• Participate in team meetings and contribute to continuous improvement initiatives in the discharge planning process.
• Coordinate with services in marker to assure high quality care for patients.
• Care coordination for high risk patients at home to prevent hospitalization and optimize care.

Qualifications:

• Bachelor’s degree in Nursing, Social Work, or a related field (preferred).
• Experience in discharge planning or patient education (minimum of 2 years preferred).
• Strong interpersonal skills with the ability to communicate effectively with patients and families.
• Ability to interface with social workers and discharge planners in hospitals and SNFs to facilitate referrals and coordinated care.
• Knowledge of community resources and services for post-discharge care.
• Excellent organizational skills and attention to detail.
• Ability to work collaboratively within a multidisciplinary team.