✨ About The Role
- Responsible for patient case management for longitudinal engagement, coordination for discharge planning, transition of care needs, and outpatient patient management through the care continuum
- Develops patients' action plans and/or discharge plans
- Coordinates care with hospitals/physician team, acute or skilled facility staff, ambulatory care team, and the member and/or family/caregiver
- Provides continuity of care for members to an appropriate lower level of care in collaboration with the care team
- Acts as an advocate for patients and their families, guiding them through the health care system for transition planning and longitudinal care
âš¡ Requirements
- 3+ years of diverse clinical experience, preferably in caring for acutely ill patients with multiple disease conditions
- Proven knowledge of utilization management, quality improvement, and discharge planning
- Ability to problem solve and identify community resources
- Strong planning, organizing, conflict resolution, negotiating, and interpersonal skills
- Current, unrestricted RN license, specific to the state of employment or a compact nursing license