- Screens all patients for clinical, psychosocial, financial, and other factors may affect the progression of care and collaborate with patients/families/caregivers in goal setting that is reflective of the patient's needs.
- Evaluates the patient's/family's/caregiver's level of understanding and engagement with the progress toward goals and incorporates findings into the plan of care.
- Arranges services among community agencies, provider, patient/family/caregivers, and others involved in the plan of care.
- Provides patient/family/caregivers available tools/ resources including pertinent quality measures to make informed choices.
- Develops a plan that is clinically appropriate and focused on the patient's care needs and goals for care and treatment plan is consistent with patient choice and available resources.
- Facilitate bi-directional communication to enhance the handover of care from one setting and arrange/ ensure all elements of transition plan are implemented and communicated to key stakeholders including, not limited to, the health care team, patient/family/caregiver, payers, and post-acute providers.
- Identify available community resources/potential partners and advocate for resolution of gaps in the available resources and processes.
- Maintain knowledge of and ensure compliance with the federal, states, and local organization and accreditation requirements that not only impact their scope of services but affect their ability to advocate for the patient.
- Ensure the patient is in the appropriate status, level of care and length of stay for the patient's clinical condition and participates in multidisciplinary rounds with the care team.
- Follows through with appropriate intervention and documentation to facilitate discharge when a patient fails to meet medical necessity.
- Identify and address avoidable delay practice patterns that may require modification to support cost-effective care. Uses escalation process as needed.
- Educates patients/families/caregivers on the financial impact of their care options.
- Tracks avoidable delays/days as well as over/under utilization of resources.
- Participates in the development of performance improvement activities relevant to identified opportunities.
- Recognizes situations that require referral to quality or risk management and makes a timely referral.
- Delegates appropriate tasks within the care coordination team.
- Bachelor's Degree required. BSN preferred.
- Licensed as a Registered Nurse in the state of Florida.
- Minimum of 3-5 years discharge planning, case management, managed care, or Registered Nurse experience in a medical setting preferred.
- Case Management Certification preferred.
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Registered Nurse Care Coordinator-PRN - Naples, FL, United States - Savista
Description
Here at Savista, we enable our clients to navigate the biggest challenges in healthcare: quality clinical care with positive patient experiences and optimal financial results. We partner with healthcare organizations to problem solve and deliver revenue cycle improvement services that enable their success, support their patients, and nurture their communities, all while living our values of Commitment, Authenticity, Respect and Excellence (CARE).Essential Duties and Responsibilities:
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SAVISTA is an Equal Opportunity Employer and does not discriminate against any employee or applicant for employment because of race, color, age, veteran status, disability, national origin, sex, sexual orientation, religion, gender identity or any other federal, state or local protected class.
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