Under general supervision, facilitate and coordinate the care delivered to an assigned group of patients through multidisciplinary and patient/family collaboration.
Conduct assessments, planning, support, and evaluation of patient care and related outcomes.
Facilitate appropriate status and level of care, screening for high risk and transition of care needs.
Work with patient and family to identify goals and outcomes, developing evidence‑based interventions and care plans.
Implement care plans and conduct systematic and timely evaluation of outcomes of nursing care.
Document care according to organizational standards, contractual and regulatory requirements.
Advocate to secure benefits for patients and identify potential barriers to payer coverage.
Coordinate community resources and provide care management to appropriate patients according to organizational policies and payer guidelines.
Requirements
Associate's Degree
1-3 years clinical experience in a hospital, acute care, home health/hospice, direct care or case management required.
Bilingual in English/Spanish preferred.
RN-Registered Nurse - DORA - Department of Regulatory Agencies Required and BLS-Basic Life Support (BLS/CPR) - AHA - American Heart Association Required
Knowledge and understanding of case management/coordination of care principles, programs, and processes in either a hospital or outpatient healthcare environment.
Strong customer service orientation and aptitude.
Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action.
Proficient in Microsoft outlook, Word, and Excel
Experience with electronic health records and documentation of care coordination services preferred.