Responsible to facilitate care along a continuum through effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient's resources and right to self-determination. Assumes responsibility to assess the patient for transition needs including identifying and assessing patients at risk for readmission. Responsible to assess the patient for transition needs including identifying and assessing patient at risk for readmission. Conducts complex psycho-social assessment and intervention to promote timely throughput, safe discharge and prevent avoidable readmissions. Integrates national standards for case management scope of services including: Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction; Care Coordination by demonstrating throughput efficiency while assuring care is the right sequenced and provided at the appropriate level of care; Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy; and Education provided to physicians, patients, families and caregivers; Participates in planning the social work component required to selected hospital programs; Provides in-service education for staff; and collaborates with community providers to develop educational resources appropriate for staff and patients/patient representatives. Completes established competencies for the position within designated introductory period. Other related duties as assigned.
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Job Type
Full-time
Industry
Hospitals