Responsible for assessing the physical and psychosocial needs of patients and families and provides intervention to meet those needs utilizing personal, family, and community resources. Coordinates with clinical and social service providers across traditional and nontraditional settings including, but not limited to hospitals, primary care offices, homes, social service agencies. Coordinates with health system case managers and leads across boundaries.
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Plan and execute interdisciplinary case conferences/team meetings and clinical rounds.
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Forge and nurture partnership with hospitals, medical offices and local service organizations to broaden support services for patients.
Implements policies and procedures to ensure that patients are discharged from the hospital with appropriate support systems to prevent re-admission.
Demonstrates the knowledge and skills necessary to provide care appropriate to patient population and within clinical competency. Demonstrates knowledge of the principles of growth and development and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify the requirements of each patient, and to provide the care needed as described in departmental policies and procedures.
Works collaboratively with hospital staff and other community/human services agencies to coordinate intervention activities; ensures that patients receive efficient services for problem resolution.
Utilizes computer and information systems to enter, format data and generates statistics, computations, tables, charts and graphs.
Maintains confidentiality of information in accordance with HIPAA/compliance policies and procedures.
Completes required continuous training and education, including department specific requirements to maintain knowledge of case management and utilization review practices. Responds to problems/opportunities to improve work environment and participates in unit based performance improvement activities.
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Attends in-services, educational programs, conferences and other meetings as required.
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Supports and is involved in the organization’s Performance Improvement initiatives.
