Job Summary:
Acts as a patient advocate. Guides patients through the clinical care system, establishing contact with new patients and/or family members, or caregivers. Understands the clinical care options for patients and directs them to healthcare services within the organization, at outside facilities and within the community for timely treatment and recovery. Actively identifies and addresses population and patient specific barriers to care that might keep the patient from receiving timely and appropriate treatment. Coordinates the continuum of care for patients post-hospitalization. This position works closely with case managers, discharge planners and home health staff to monitor the recovery of high-risk patients and coordinate follow-up care, including maintaining patient's initial follow-up primary care visit, facilitating home health services, and coordinating care enhancements, as needed following discharge.
Job Requirements:
Education and Work Experience:
- Bachelor's Degree in Nursing (BSN): Preferred
- Case management experience in a healthcare setting: Preferred
- Experience in acute, emergency or perinatal setting: Preferred
Licenses/Certifications:
- Registered Nurse (RN) licensure in the state of practice: Required
- Cardiopulmonary Resuscitation (CPR) certification or Basic Life Support (BLS) certification from approved vendor per AH policy: Required
Facility Specific License/Certifications:
- Basic Life Support (BLS) certification from approved vendor per AH policy: Required
Essential Functions:
- Assists patient and family in identifying and accessing appropriate institutional and community resources. Implements appropriate care intervention and follow-up to ensure patients receive timely care, preventing delays and access to appropriate services and follow up instructions from managing physicians. Interacts with other hospital departments in fulfilling the needs of the patients.
- Makes initial and ongoing assessments of patient needs (clinical, emotional and social) and makes appropriate recommendations or referrals for care. Facilitates the timely completion and confidential reporting of diagnostic testing results to patients and families with interpretation, as well as to ordering clinicians through active tracking of ordered tests.
- Collaborates with the team of patient, family, and healthcare providers in providing patient care in a safe, healing, humane, and caring environment. Provides learning opportunities for patients/family members and team members. Directly provides health information to patients, families, and treatment team.
- Documents coordinator and patient interactions in electronic or hardcopy chart in a manner consistent with hospital standards. Creates reports from patient data such as volumes and outcomes. Monitors, analyzes, and reports to clinic governing body clinical and operational key indicators and identifies opportunities for performance improvement
- Identify both index and readmission patients who are high-risk for readmissions and who may require additional interventions and education. Help monitor the recovery of high-risk patients, coordinating follow up care, including follow up phone calls to the patient post-hospitalization, assisting as needed with scheduling of primary or specialty care visit and facilitating home health services.
- Performs other job-related duties as assigned.
Organizational Requirements:
Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply.
