care coordinator, care management - Manahawkin
1 week ago
Job summary
The Care Coordinator will coordinate communicate and facilitate the clinical progression of patients treatment and discharge plan assessing planning facilitating with patients families and multidisciplinary teams to meet treatment goals expected length of stay arranging for appropriate next level of care.
Responsibilities
- Assesses patients by screening for potential discharge needs regardless race age sex religion diagnosis ability to pay meets directly with patientfamily assesses needs develops individualized care plan collaboration physician other members healthcare team facilitates communication coordination between healthcare team involves patientfamily decision making process minimize fragmentation services manage resources remove barriers plan care maintains current information community resources refers patients those community resources appropriate patients care works collaboratively all team members multidisciplinary post acute care teams secure timely appropriate transitions next level care develops discharge plan collaboration patient support persons identifying goals provide maximum benefit each patient ensures medical record reflects education provided coordination services referrals made authorizations obtained participates actively committees workgroups meetings identifies refers quality issues review Quality Management Program participates multidisciplinary rounds specific assigned units brings forth issues impact discharge length stay timely manner discussion resolution performs reassessments evaluates progress against plans revises as needed ensures medical record reflects reassessment least weekly change medical condition affecting plan providespatientsfamilieswithresourcesdischargeoptionseducatesregardingrisksbenefitsdischargeroptionsavailablehealthcarebenefitsutilizesocialdeterminantshealthscreeningtoolsresourcesintakeassessmentcollaboratesallmembersthemultidisciplinaryteamsupportfunctions crisis intervention counseling support referrals abuse neglect reporting adoption planning guardianship psychosocial assessments observation management capacity management hospital throughput makes referrals requiredneededacute rehabilitation facilities sub acute rehabilitation facilities long term care facilities assisted living facilities adult day program Level PASRR screening EARC screening home hospice durable medical equipment transport dialysis financial assistance medication assistance palliative Care boarding home placement mental health services homelessness placement substance abuse placement Division Child Protection Permanency Adult Protective Services maintains annual competencies training continuing education applicable platforms Epic Xsolis Cortex BI Google Suites other dutiesprojectsassignedadherestoHMHOrganizationalcompetenciesstandardsbehavior.
Job description
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