Care Manager SNF Coordinator
Company: Crystal Run Healthcare LLP
Posted on: September 18, 2022
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
- 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
- Develop and implement care plans with provider, patient and
family and maximize healthcare outcomes and facilitate
- 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
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