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Job Description: Work closely with interdisciplinary care team and technology to identify high-risk, complex patient cases; manage care, including referral management, care planning, post-discharge planning and coordinating community-based and transitional care Conduct individualized clinical evaluations of patients, their health needs and concerns; develop personalized action plans, provide education and issue referrals for care management programs; monitor patients' progress in meeting established goals and modify care plans accordingly Use evidence-based, comprehensive care plans to manage patients Develop a cohesive and strong team-oriented relationship with physicians, nurses and other healthcare professionals; evaluate and report on patient health outcomes and work in partnership with interdisciplinary healthcare team to facilitate the best in patient care Direct discharge planning process in support of treatment adherence and medication compliance; assist with transitions for patients discharged from an in-patient hospital to a skilled nursing facility Guide, intervene and advocate on behalf of patients, their caregivers and/or families in regards to navigating and comprehending the healthcare system; coordinate resources in the community to ease transition
Date Posted: 28 May 2025
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