p>This individual's responsibility will include the following activities: a) complex psycho-social transition planning assessment and reassessment and intervention,
b) assistance with adoptions, abuse and neglect cases, including assessment, intervention and referral as appropriate to local, state and /or federal agencies,
c) care coordination,
d) implementation or oversight of implementation of the transition plan,
e) leading and/or facilitating multi-disciplinary patient care conferences including Complex Case Review,
f) making appropriate referrals to other departments,
g ) communicating with patients and families about the plan of care,
h) collaborating with physicians, office staff and ancillary departments,
i) assuring patient education is completed to support post-acute needs ,
j) timely, complete and concise documentation in Tenet Case Management documentation system,
k ) maintenance of accurate patient demographic and insurance information,
l) and other duties as assigned.
The individual in this position is responsible to facilitate care along a continuum through effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient's resources and right to self-determination.