This is an ideal opportunity for a clinician who thrives in a collaborative environment, enjoys problem-solving, and is passionate about advocating for patients and improving outcomes.
Conduct comprehensive patient assessments, including clinical, psychosocial, functional, and financial needs
Develop and manage individualized care plans in collaboration with physicians, nurses, therapists, and social services
Coordinate transitions of care (hospital to home, rehab, or long-term care) to ensure continuity and safety
Partner with insurance providers to secure authorizations and ensure appropriate utilization of services
Identify and remove barriers to discharge, including social, financial, and logistical challenges
Serve as a patient advocate, ensuring needs and preferences are represented in care decisions
Educate patients and families on diagnoses, treatment plans, and post-discharge care
Connect patients with community resources, support services, and post-acute providers
Facilitate referrals to specialized services such as housing, behavioral health, and legal resources
Monitor patient progress, adjust care plans, and track outcomes and quality metrics
Maintain accurate, timely documentation of assessments, interventions, and care plans
Participate in interdisciplinary rounds and care conferences
