Employment Type:

Shift:

Description:

ESSENTIAL FUNCTIONS:

• Interacts with patients, family members, healthcare professionals, and community and state agencies to ensure the patient's progress in the acute episode of care through post discharge is quality driven, while being efficient and cost effective.
• Serves as a liaison between the hospital and community agencies or facilities for the exchange of clinical and referral information.
• Identifies high risk patients from a psychosocial/financial perspective, through screening mechanisms, and assesses the needs of patients and families and provides information, support, counseling, case facilitation, and timely, accurate referrals to appropriate resources.
• Ensures that a transition plan for ongoing ...