Diane Baez

Assesses patients to determine the appropriate level of post-acute care services within CMS/payor guidelines and reviews the options with the patient and/or designated representatives. Primary assignment includes one level of post-acute care (SNF or IRF). Gathers and communicates significant referral information to appropriate staff within the continuum to promote continuity of care post-acute discharge. Responsible for all referral data collection as required. Responsible for supporting the referral development goals for the post-acute continuum and to educate/liaison with physicians, physician office staff, APRN, PA, nursing case managers and social workers to facilitate the patient's discharge process. Responsible for growing the post-acute business and developing positive and effective relationships within the community, facilities, and other liaisons.

• Ensured timely and accurate documentation of patient data, maintaining compliance with regulatory requirements.
• Facilitated smooth transitions between levels of care by coordinating necessary services, medical equipment, and provider referrals.
• Reduced hospital readmission rates by providing thorough discharge planning and follow-up care coordination.
• Prioritized caseload effectively, addressing urgent matters promptly while still managing ongoing responsibilities with a high degree of professionalism.

• Maintained accurate documentation on all cases, ensuring compliance with regulations and confidentiality requirements.
• Conducted thorough assessments of clients'' situations, identifying issues, goals, and necessary interventions.
• Monitored ongoing cases closely, adjusting case management strategies as needed based on evolving circumstances or new information.
• Educated clients on available programs, benefits, and services, empowering them to make informed decisions about their care needs.
• Baker Act placements from ER. High homeless population service hospital.

• Assessed patients for IRF level of care. Working closely with acute physicians and IRF medical director.
• Confirmed all insurance benefits met standards of admissions as dictated by policy.
• Case management of patient during length of stay, setting up needed services at discharge.
• Social support for families in time of crisis.

• Interviewed clients, families, or groups to assess situations, limitations and issues and implement services to address needs.
• Collaborated with multidisciplinary teams to ensure appropriate care coordination and resource allocation for clients.
• Educated families on available community resources, connecting them with essential services such as housing assistance, financial aid, or healthcare providers.