Performs and oversees transitional care management processes to recently discharged patients of HHC, providing the best possible care options for patients and their families. Working directly with Care Management and HHC Independent physicians to collaborate, monitor and evaluate patient status post discharge focusing on intermediate goals, outcomes, medication reconciliations ensuring the prevention of patient and family confusion, hospital readmissions and ensuring overall good patient hand offs from hospital to home. Oversees the appropriate after care activities to include but not limited to Paramedicine, Home Health, DME, Rehab services, Educare, Pharmacy and transportation needs. Also serves as direct resource for staff, and Independent physicians regarding their patients care after hospital discharge. Job Summary: Responsible for enhancing the patient experience by providing a seamless navigation process from diagnosis to survivorship. Responsible for collaborating with physicians and members of the interdisciplinary teams to triage, coordinate, and consistently manage patient care by educating, providing a link to research, serving as the primary point of contact for patients and families and providing indirect patient care. Works with patients and families to answer questions, provide emotional support and solve issues concerning the cycle of care.
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Job Type
Full-time
Career Level
Mid Level