Oversee the interdisciplinary plan of care from admission to discharge, developing seamless transition plans that integrate patient preferences, advocate for resources, and eliminate barriers to care. Monitor patients' medical necessity and appropriate level of care through ongoing clinical assessments, ensuring efficient resource utilization and collaborating with payers to optimize insurance benefits. Maintain continuous communication with physicians, the care transition team, and nursing staff to ensure effective implementation, execution, and reevaluation of the care plan. Serve as a clinical resource for accurate medical record documentation and level of care recommendations, acting as the primary liaison between patients, families, and post-acute service providers.
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Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree