Job Summary

Coordinate patient care through multidisciplinary team approach, ensuring quality and cost-effective outcomes. Manage treatment plans, coordinate care with physicians, nurses, and other staff to achieve desired results.

Key Responsibilities

* Adhere to Patient Centered Medical Home core expectations
* Identify patients requiring case management interventions using established procedures
* Perform assessments, collect data, review, and analyze information to inform treatment decisions
* Assess patient clinical, psychosocial status, and current treatment plans
* Develop collaborative relationships with other departments/services and community health care agencies to facilitate quality care
* Assist patients and families in setting goals for individualized patient-centered care
* Develop comprehensive multidisciplinary plan of care effectively utilizing tools and resources
* Conduct timely discharge planning to anticipate patient needs
* Monitor and evaluate short-term and long-term patient responses to interventions
* Review variances from standardized protocols of care and implement resolution strategies
* Facilitate conferences to provide ongoing evaluation of interdisciplinary dynamics, goals attainment, and treatment management
* Ensure continuity of patient care throughout all healthcare settings by promoting effective communication among healthcare team members
* Participate in team meetings as directed and attend meetings representing department or hospitals within related committees or the community as assigned by supervisor
* Enhance professional growth and development through participation in educational programs, reading current literature, attending in-services, meetings, and workshops
* Follow patient safety-related policies, procedures, and protocols
* Demonstrate proactive approach to patient safety by seeking opportunities to improve patient safety through questioning of current policies and processes
* Identify and report/correct environmental conditions and/or situations that may put a patient at undue risk
* Report potential or actual patient safety concerns, medical errors, and/or near misses in a timely manner
* Encourage patients to actively participate in their own care by asking questions and reporting treatment or situations that they don't understand or may