Integrates health care for residents from pre-admission to post discharge. This is accomplished through the coordination and sequencing of the resident's care. Integration enhances resident flow and interdisciplinary communication promotes early intervention. Seeks to evaluate outcomes based on an integration among established clinical, financial and utilization data. Functions in structured and unstructured health care settings described as a geographic and/or situational environment that may not have established policies and procedures. Utilizes independent nursing judgment when integrating health care. Has knowledge of and utilizes appropriate age-specific structured care methodologies, such as protocols/integrated clinical pathways/guidelines/standards of care relating to the overall health care needs of the residents. Interviews potential residents and assesses residents in compliance with regulations, policy and procedure. Uses assessment information for admission and continued stay in the assisted living community. Ensures all residents meet assisted living qualifications as identified in the occupancy agreement. Establishes a service plan for each resident and evaluates on an on-going basis. Able to work with growth and development needs of client populations in clinical area. Ability to communicate with residents, family members and others on the health care team. Coordinates, facilitates, and negotiates with others. Monitors, evaluates and trends patient/residents responses utilizing structured care methodologies. Fiscally responsible. Controls variances and duplication. Must demonstrate independence, assertiveness and critical thinking when working with patients and co-workers. Ability to document clearly. Ability to solve problems. Self motivated. Works with little direction. Ability to incorporate teaching/learning principles and adapt teaching to age group. Ability to facilitate groups and implement projects when necessary. Must be able to establish priorities, have strong flexibility and organizational skills. Must be knowledgeable about reimbursement for services provided. Will be required to work primarily day hours, scheduled weekends, and occasional evenings. May be exposed to communicable or infectious disease, hazardous materials and injury from performance of assigned duties. Is subject to multiple sensory and environmental stressors.
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Career Level
Mid Level
Industry
Hospitals
Number of Employees
5,001-10,000 employees