RN Care Coordinator

Highland Hospital is seeking a full time Case Manager to join the team. Hours will be Monday-Friday from 8am-4:30pm. Under general direction, the Clinical Care Coordinator/Case Manager’s role is to coordinate interdisciplinary care planning to achieve timely and safe discharge and/or to coordinate access and utilization management, proactive patient management, care facilitation and treatment planning functions. The Clinical Care Coordinator/Care Manager coordinates care along with unit staff (Nursing, Providers, Consulting Services, Social Work) and providers caring for the patient at discharge to assist in facilitating a patient focused plan of care aimed at ensuring a safe transition from hospital to home for adult acute care patients. Essential functions include, but are not limited to:

• Identify patient discharge needs and potential barriers

• Assists with closing gaps in medical care upon discharge by utilizing community resources

• Communication with in-network PCP offices to ensure a transition of care to the community setting

• Identify resources for patient self-management planning and discharge

• Assist in developing and implementing care plans for medically complex patients

• Prepares patient for discharge by referring for home care services (skilled nursing, PT, OT, SLP) and DME

• Complete the Patient Review Instrument

• Other duties as assigned