Overview

This position provides comprehensive care coordination, supporting a holistic and coordinated approach across the continuum of care. This position assists with informed decision-making; collaborating with a multidisciplinary team to allow for timely screening, diagnosis, treatment and increased supportive care throughout the patient experience. This position provides individual assistance to patients, families and caregivers to help identify and overcome barriers which may hinder quality medical and psychosocial patient care.

 

Responsibilities

Assesses the patient's plan of care and develops, implements, monitors and documents the utilization of resources and progress of the patient through their care, facilitating options and services to meet the patient's health care needs.

Assists the patient/family through diagnostic services, treatment and care. Coordinates disease care using an interdisciplinary holistic approach, making appropriate referrals and consultations in coordination with physicians and providers.

Ensures that the patient and family understand the diagnostic processes, care strategy and recommended actions, and are provided with appropriate information in coordination with physician and health care providers. Responds to patient requests for information regarding the disease process, expected side effects and community resources.

Evaluates patient's functional abilities and limitations. Determines if intervention is needed. Establishes treatment goals that are functional, measurable, patient related and reflect key limiting factors. Establishes and implements a plan of care to achieve treatment goals. Collaborates with patient and family when setting goal; initiates discharge planning. Recommends additions to or modifications of referring orders.

Supports process improvement activities for populations of patients to achieve the optimal clinical, financial, operational, and satisfaction outcomes. Participates in staff development to maintain current standards of practice and ensure the highest quality of care. 

Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provides all customers of Foundation Health with an excellent service experience by consistently demonstrating our core and leader behaviors each and every day.

Qualifications

Must possess knowledge as normally obtained through the completion of a Bachelor's degree in nursing or related field.

 

Depending on area of focus, requires a current RN licensure, PT licensure, or OT licensure in the state of practice. BLS certification required.

 

Requires a proficiency level typically achieved with 5 years clinical experience. Requires excellent organizational skills and clinical knowledge regarding specialty care services, as well as care coordination of services, legal and financial aspects of diagnostic services and health services in specialty area. Requires effective communication and writing skills, good time management skills and knowledge of word processing and database software applications. Requires the ability to teach both clinical and non-clinical personnel regarding care and diagnostics services. Also requires a good understanding of process improvement.

 

PREFERRED QUALIFICATIONS

Current certification in specialty area preferred. Prior Case Management experience preferred. Depending on area of focus, experience with mild traumatic brain injury treatment(s), outreach in the community, and, research related to mTBI is preferred.