Care Manager SNF Coordinator

Company: Crystal Run Healthcare LLP
Location: Middletown
Posted on: September 18, 2022

Job Description:

Provides medical case management services to patients admitted for short term rehab. Identifies and accepts care management referrals. Assesses patients healthcare needs and identifies appropriate resources. Promotes and coordinates optimum healthcare services, with cost effective solutions. Coordinates care across the healthcare continuum of care between facilities and providers. Promotes wellness and autonomy through education and advocacy for patients and care givers. Essential Duties and Responsibilities

• Identifies and focuses on short term high risk patients, barriers and the driving force within their care
• Coordinate care between healthcare settings including reviewing documentation and facilitating communication between providers
• Travels to hospitals and SNF facilities as directed, and works with clinical teams to develop a care plan that promotes safe transitions and appropriate utilization of health care resources.
• Participates as directed with hospitals and SNF's on committees that oversee quality of care delivery of Crystal Run patients.
• Communicates with hospital staff to identify potential SNF admissions and readmissions.
• Assessment and reassessment of patients to prioritize needs as patients move through the healthcare system to appropriate level of care
• Develop and implement care plans with provider, patient and family and maximize healthcare outcomes and facilitate wellness.
• Initiates appropriate interventions based on needs assessment, including referrals for Hospice, Palliative Care, RPM Telemonitoring, home care, DME and other community resources
• Reviews documentation in Electronic Records for potential barriers, needs, care history, and medications (hospital, SNF, Crystal Run E.H.R). -
• Communicates by phone, in person or in writing with patients, physicians and medical facilities as needed or requested.
• Functions as a recognized site team member through provision of regular follow ups for high risk patients, facilitation of access to PCP, specialist and facilitating special arrangements (home care, hospice, palliative care).
• Collaborates with Primary Care providers, hospital staff, specialists, patients' insurance carrier, office staff and facilities to assess the patient's healthcare needs. -
• Educate patients and family members on disease processes, importance of preventative screening, medications, and safety to optimize autonomy and wellness. QualificationsEducationPreferredAssociates in Applied Science or better in Nursing or related field.

Keywords: Crystal Run Healthcare LLP, Middletown , Care Manager SNF Coordinator, Executive , Middletown, Connecticut