Job Summary : This role supports patients transitioning before and after acute care episodes, focusing on medical, psychosocial, and economic factors. Emphasis is placed on assisting individuals with chronic conditions and functional limitations to navigate healthcare systems efficiently, reducing fragmentation and duplication while promoting coordinated services. The goal is to enhance patient engagement, satisfaction, and overall health outcomes.
Essential Responsibilities :
- Assist with initial screening and evaluation for non-complex planned admissions under supervision.
- Facilitate access to services such as skilled nursing facilities, home care, hospice, infusion therapy, long-term acute care, durable medical equipment, and transportation.
- Monitor and reassess care plans for low-risk patients, ensuring timely updates based on condition changes.
- Develop and maintain partnerships with physician practices, outpatient providers, and community services.
- Serve as a liaison for post-acute care providers and physician practices regarding care provision.
- Promote system integration and interdisciplinary collaboration to ensure continuity of care.
- Maintain accurate contact information for community partners and manage department resources.
- Participate in meetings and initiatives focused on transitions of care within the healthcare system and community.
- Support utilization review and case management assignments as requested.
- Ensure accuracy in disposition coding and after-visit summaries.
- Manage department communications, including phone and visitor inquiries.
Skills and Abilities :
Strong knowledge of healthcare industry regulations, including discharge planning, abuse prevention, advanced directives, safety, and privacy.Skilled in promoting patient and family engagement with empathy and respect for individual rights.Excellent communication skills, both written and verbal, with the ability to relate to diverse populations.Ability to handle sensitive and confidential information professionally and maintain composure in stressful situations.Logical thinker capable of processing complex information and ethical / legal issues.Familiarity with government programs and social service agencies to assist patients in accessing resources.Independent decision-making skills and ability to manage multiple demands in a dynamic environment.Willingness to seek supervision and consultation appropriately.Education and Experience :
Bachelor's degree preferred from an accredited institution, with additional healthcare experience valued. Candidates with relevant certifications and substantial healthcare experience will also be considered.
Work Shift : 4th Shift
Scheduled Weekly Hours : As needed (PRN)
Location : Serving the Midwest regional healthcare community.