Palm Beach Gardens, FL28 days ago
The individual’s responsibilities include the following activities: (a) care coordination, (b) transition-planning assessment and reassessment, (c) implementation or oversight of implementation of the transition plan, (d) communicating with patients, families and the healthcare team regarding the plan of care, (e) leading and facilitating unit TEMPO (Team Engagement to Manage Patient Outcome), (f) leading and facilitating multi-disciplinary patient care conferences, (g) active participation and knowledge sharing in Complex Case Review, (h) identifying and escalating complex patients to CM leadership and physician advisor, (i) collaboration with the healthcare team including physicians, office staff, ancillary departments, payors, and post-acute facilities, (j) assuring patient/family education is completed to support post-acute needs, (k) timely, complete and concise documentation in the Case Management system, (l) maintenance of accurate patient demographic and insurance information, (m) identification and documentation of potentially avoidable days, (n) identification and reporting over and underutilization, (o) and other duties as assigned. The RN Case Manager 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.