Cambridge, MA30+ days ago
Place referrals to and collaborate with our community agencies such as VNA, Hospice and other home care agencies Collaborate with and make referrals to specialists including Cardiology, Endocrine, Genetics, Nutrition, Social Work, Physical Therapy and Palliative Care Serves as contact and facilitator to receive consults and patient information Coordinates and insures all patient scheduling including but not limited to consultation, diagnostic and treatment procedures Gathers information for history and physical Performs and documents evaluations and assessments of patient Assists in development of patient/family educational materials Participates in patient rounds and case conferences Updates clinical knowledge and skills through consultation, formal and informal education, and review of literature for self and clinical team Provides leadership for process improvement related to the care of these patients Acts as a liaison between the patients, families, and caregivers and the providers to optimize outcomes Makes and answers patient phone calls, both pre and post treatment/procedure, from patients referring providers, and outside facilities (hospitals, rehabilitation centers, physician offices). Knowledge: Ability to demonstrate in-depth knowledge of concepts, practices and policies with the ability to use them in complex varied situations Team Work: Ability to act as a team leader for small projects or work groups, creating a collaborative and respectful team environment and improving workflows.