Overview

Facilitates patient transitions through the health care system by providing information and promoting linkage between patient and healthcare providers. Functions as navigator, patient educator, advocate, and patient empowerment facilitator. Provides information and guidance to the patient and/or caregiver resulting in effective care transitions, improved self-management skills and knowledge, and enhanced communication between the patient and the healthcare team. Serves as the liaison between the patient and the healthcare delivery team. Also provides administrative and customer service support.

May require travel.

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  Receives the list of "hospitalized" or "service interrupted" patients and prioritizes to assess for follow-up needed/actions

  
  

  required

  
  


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  Conducts "at the bedside" meeting with the patient and/or caregiver as requested; follows the patient during the post-

  
  

  discharge transitional phase, navigating patient care in conjunction to other provider care coordinators and members of the internal care team. Follows up to ensure that the patient is following the transitional care guidelines

  
  



• Understands and discusses the patient-defined healthcare and functional goals and anticipated post-discharge care needs to ensure a smooth transition home or to other level of care setting



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  Reviews hospital Discharge Summary and Medication List with patient/caregivers and assures that transitional care

  
  

  processes are implemented. Escalates medication reconciliation to Nurse Practitioner, as needed

  
  


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  Provides care management for assigned patients from assessment to discharge. Works closely with the Care team to

  
  

  monitor and track patient progress. Prepares detailed, accurate and timely documentation. Facilitates periodic case

  
  

  record reviews and case conferences with the Care team for assigned patients. Reviews new cases for completeness

  
  

  of documentation

  
  


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  Establishes and promotes an ongoing collaborative relationship with direct caregivers, hospital administration,

  
  

  physicians, nurses, discharge planners, case managers, social workers, unit clerks, homecare agencies and other

  
  

  facility personnel

  
  

CA2019

• Valid driver's license or NYS Non-Driver photo ID card, may be required as determined by operational/regional needs




• Associate's degree in Human Services or a related field or the equivalent work experience required. Bachelor's degree in a human services or related field preferred



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  Minimum of two years of customer service experience in the medical field (i.e. hospital, long term care, home care, medical office) required. Experience entering data, navigating and retrieving information through computer systems required. Proficient computer skills in Microsoft office preferred. Ability to adapt to change and work in a team based environment required. Strong follow up skills required, as well as the ability to manage multiple priorities

  
  

  required. Demonstrated ability to educate clients, conduct phone interviews/coaching, and coordinate services for multiple chronically ill patients required. Bilingual skills may be required, as determined by operational needs. Must be organized and detail oriented