Provides case management, advocacy, and care coordination services to hospital patients in a variety of settings to assure seamless transitions in care while minimizing any associated delays or risk of readmission. Conducts early patient assessment, by case-finding and referral, to identify coordination and discharge planning needs. Creates individualized, patient -focused plan for meeting continuing care needs. Makes referrals to post-hospital care providers utilizing knowledge of community resources. Collaborates with the healthcare team to ensure discharge is timely, patient education and instructions are complete, and appropriate follow-up is established. Utilizes current clinical nursing knowledge to effectively educate patients and families about chronic disease conditions. Collaborates with staff nurses and physicians to ensure all elements for core measures have been met prior to discharge. Conducts clinical review process according to Utilization Management Plan. Identifies and intervenes in situations that pose financial risk to the patient and the organization.
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Job Type
Full-time
Career Level
Mid Level
Number of Employees
501-1,000 employees