Provides expert, individualized coordination of care to patients and families. Conducts initial and ongoing comprehensive physical and psychosocial assessments to identify needs and areas for intervention. Arranges referrals to specialists when indicated and supports adherence to treatment plans, including physician visits for evaluation and ongoing management. Helps patients access community services and resources to improve their health and well-being. Educates patients and families about disease processes and plans of care, including treatment options, to support informed decision-making. Provides emotional support and counseling to help patients and families adjust to illness, navigate transitions, and adhere to treatment plans. Evaluates physical and emotional recovery after treatment and uses appropriate resources as needed. Encourages patients to set appropriate goals and discuss advance care planning and advance directives. Builds relationships with clinicians involved in patient care and promotes a patient-centered approach. Partners with the healthcare team to coordinate transitions between hospital, primary, and specialty care. Facilitates proactive discharge planning and follow-up to promote better outcomes, shorter stays, and fewer readmissions. Protects patient privacy and confidentiality when releasing information. Performs other duties as assigned.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed