Responsibilities:
- Screens all patients for clinical, psychosocial, financial, and other factors that may affect the progression of care and collaborates 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, providers, 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 an appropriate plan that focuses on the patient’s needs, goals of care, and treatment plan that is consistent with patient choice and available resources.
- Facilitates 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, but 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.
- Identify and address discharge delays and 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 discharge delays 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.
Education and Qualifications:
- Licensed as a Registered Nurse in the state of Florida required.
- Compact license holder also preferred for this role.
- Minimum of 3 years discharge planning, case management, managed care, or Registered Nurse experience in a medical setting preferred.
- Case Management Certification preferred.
- Must be willing to work onsite in Ortigas.
