Summary
Job Summary
Facilitates cost-effective, quality patient transitions of care and outcomes by collaborating with staff and providing guidance, education, and support to assigned patients. Job Responsibilities
Completes comprehensive assessment of medical record and knowledge of patient's medical condition, financial status, emotional needs, and support systems. Collaborates with Case Management Medical Director, Director, and/or Manager on complex discharge planning issues and delays in service. Interview patients, assesses priorities, and develops appropriate discharge plan. Works in collaboration with the Social Worker and interdisciplinary care team members to ensure quality support of care and safety of discharge. Assists patients/families with referrals to community agencies, post acute providers, and provide education and resource information. Documents precisely and timely in the medical r...