In this role, the selected candidate will provide intensive case management to high risk patients post discharge; directly involved in managing the multiple elements that comprise a persons successful transition from hospital to home.
The Community Care Coordinator is a member of Interdisciplinary Team (IDT) caring for the patient in ensuring the patients individual needs are identified and addressed in a timely manner, act as patient advocate to address primary physical and social needs including assessing and linking community resources available to the patient, as well as ensuring patients assigned have timely access to services they need while respecting the rights and wishes of the patient and family.
In this role, you will build meaningful relationships with a specified number of seniors and their families as you provide assistance with activities of daily living, attend to individual care needs and get to know their unique preferences and personalities.
In this role, you will provides a range of services, including skilled nursing care, assisted living, post-acute medical and rehabilitation care, hospice care, home health care and rehabilitation therapy.
In this role, you will be responsible to develops effective working relationships with physicians, nurse practitioners, nurses, allied health professionals (e.G. Social workers, psychologists, etc.), medical assistants, and referral coordinators.
In this role, you will participate in departmental and company in-services as appropriate; prepare for and attend committee meetings as assigned; document all contacts in the care coordination documentation system.
In this role, the selected candidate will act as a discharge planning resource to Hospital staff involved in home care planning, and facilitates continuity of care for the patient transitioning to home based services.