Functions as a liaison for patient/family in navigating the continuum of care. Assesses, plans, coordinates, and evaluates services of patients with the goal of equipping and empowering individuals and their families to easily assess resources and adopt healthy lifestyles that will increase their ability to remain healthy at home or in the least restrictive environment. Works closely with hospitals, clinics, health care facilities, and agency clinical and administrative personnel to ensure patient care is seamless, efficient, effective and appropriate to the individual. Interacts daily with patients, medical professionals, and the community to achieve continuity of care, coordination of medical services, and to document plans of care as related to home health care and hospice services. Makes on-site consultative, educational visits in the hospital to evaluate the appropriateness of the patient's admission to continuing care services. Able to complete needs assessment considering psychosocial, physical, economic, and health literacy factors. Uses interpersonal skills and excellent communication skills to establish a rapport with the patient and forecast and prioritize his/her needs. Receives referrals and orders from physicians, hospital, and other agencies. Acts as a resource for clinical personnel. Completes accurate and appropriate documentation, logs, and/or patient forms and records to ensure compliance with regulations, agency policy, payer requirements, and standards of care.
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Job Type
Full-time
Career Level
Mid Level