Summary:

Collaborates with physicians, nurses, and multidisciplinary team members to develop a plan of care for each assigned patient from admission through discharge. Ensures patient is progressing towards desired outcomes by continuously monitoring patient care through assessments and evaluations. Assesses and responds to patient/family needs by coordinating efforts of other team members. Identifies and resolves barriers that hinder effective patient care.

NOTE:

This is not a Nursing position.

Responsibilities:

Collaborates with the interdisciplinary team and consults with nursing staff to regularly evaluate the patient's current and ongoing needs.

Collaborates closely with governmental agencies (such as DCF, APS, CMS, and KePro) to ensure safe post-acute care.

Participates in discharge planning including coordinating patient transfers to other facilities and coordination of community.

Works with patients/families to navigate through the healthcare system (post-acute choices, insurance plans, etc.) to coordinate.

Organizes and facilities care conferences with patients, families, representatives, and other members of the care team.

Assesses and initiates crisis interventions and baker act if necessary.","accountId","99482076","Memorial Healthcare 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