Coordinate the overall interdisciplinary plan of care for patient, from admission to discharge. Create plan for care across the continuum, integrating patient/family preferences and values. Serve as a resource to assess, evaluate, recommend and treat legal, neglect, substance abuse, crisis, psychosocial and various adjustment needs. Advocate for resources and removal of barriers. Maintain ongoing dialog with supervisor and care transition team members to ensure effective implementation and reevaluation of health plan. Act as a resource for adequate medical record documentation, complex level of care recommendations, and services as they relate to diagnoses, and treatment options for post-discharge care.
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Job Type
Full-time
Industry
Religious, Grantmaking, Civic, Professional, and Similar Organizations
Number of Employees
5,001-10,000 employees