Coordinates the care for groups of patients as it relates to disease management, resource utilization, access, discharge planning, quality, service and efficiently across the continuum. This is an interventional role maintaining a patient centered focus. In collaboration with patient, family, physician, and other health care team members formulates and facilitates the discharge planning activities of assigned patients. Coordinates care and monitors the utilization of resources for patients, physicians, and third-party payers. Utilizing the nursing process and critical thinking skills, coordinates the care for assigned patients. Utilizes established criteria to identify and facilitate the appropriated level of care for assigned patients. Educate patient, family, and health care team members regarding appropriate level of care. Collects and aggregates data via Allscripts automated case management system and electronic medical record documentation. Serves as an educator on the Care Management process to patients/families and other health care team members. Identifies problematic discharges where there may be issues or obstacles which impact or prolong LOS. Attends unit based problematic discharge meeting. Identifies potential risk and intervenes with system inefficiencies. Collects data as indicated to support recommended changes.
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Job Type
Part-time
Career Level
Mid Level