• Education: Graduate in Nursing or Social Work from an accredited program. Bachelor’s or master’s degree preferred
• Licenses/Certification: Nursing or SocialWorker license in the State of Wisconsin required.
• Experience: Minimum of two years of experience incase management, home health care, hospice services or a post-acute caresetting. Demonstratesknowledge of the referral source types and community resources. MDS experience preferred but not required.

• Performsonsite visits/reviews in the hospital to determine clinical needs andappropriate post-acute care facility placement.
• Followspatients from acute care setting to post-acute care setting and assistsinterdisciplinary team with discharge planning.
• Coordinatestransitions with other service providers as needed (i.e., specialty care, homehealth, palliative care, hospice).
• Identifiesopportunities to assist/refer patients in coping with diagnosis and potentialoutcomes including advanced directives, palliative care and end-of-lifeconcerns.
• Assistin completion and finalization of discharge planning assessments, level of caredetermination on admission, benefits coverage evaluation and any other requiredclinical assessments.
• Attendsinterdisciplinary team meetings for discharge planning and clinical carecoordination needs.
• Followup with patients after discharge home to ensure their accommodations are metand has direct oversight of the customer service outcomes.
• Performsother duties as assigned.

Knowledge/Skills/Abilities

• Understands Nursing Home Regulations,medications, payer sources, Therapy/Clinical Requirements for short-term rehaband long-term care.
• Knowledge of facilities clinicalcapabilities
• Understands and can navigate hospitalreferral sources.
• Ability to organize and prioritize.
• Ability to maintain confidentiality.
• Strongorganizational skills.
• Musthave proven skills in working independently, self-motivated and goal oriented.
• Abilityto communicate effectively, both orally and in written form.
• Abilityto establish and maintain working relationships with multiple and varied peopleand organizations.
• Demonstrateself-confidence.
• Abilityto work flexible hours, as job duties and responsibilities may dictate.
• Mustbe capable of maintaining regular attendance.
• Mustbe capable of performing the essential job functions of this job, with orwithout reasonable accommodations.

PhysicalDemands

• Ability to sit, stand and walk forvaried lengths of time.
• Ability to lift up to 30 pounds unassisted.

Benefits: