General Purpose of Job:
Effectively manages and coordinates the patient’s plan of care across the continuum. Works collaboratively with the interdisciplinary team enhancing the quality of patient clinical outcomes and patient satisfaction with efficient and effective utilization of resources.
This job description is intended to cover the minimum essential duties assigned on a regular basis. Caregivers may be asked to perform additional duties as assigned by their leader. Leadership has the right to alter or modify the duties of the position.
- Psychosocial Assessment and Interventions:
- Conducts a preliminary risk screening, assesses patients and family’s psychosocial risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems, reaction to illness and ability to cope.
- Performs comprehensive assessments of patients’ medical condition, adjustment, support systems, finances, housing, behavior, cognition, abuse factors, function and abilities, legal, and substance abuse factors to identify issues, which must be addressed prior to discharge.
- Provides intervention in cases involving child abuse/neglect, domestic violence, elderly abuse, institutional abuse and sexual assault.
- Serves as a resource person and provides counselling and intervention related to treatment decisions and end-of-life issues.
- Develops long and short-term plans with the patient/family to address problems identified.
- Provides emotional support to help patients cope with the disruptions and distresses associated with their illness/injury. Observes patient’s right to self-determination and confidentiality.
- Intervenes with problems of: Adult Abuse, Suicide, Guardianship, Conservatorship, Durable Power of Attorney, and Mental Illness.
- Care Coordination: Coordinates and facilitates patient care progression throughout the continuum.
- A collaborative process that encompasses the following: assessment, plans, implements, coordinates, monitors and evaluates the options and services required to meet the needs of the patient.
- Works collaboratively and maintains active communication with other members of the interdisciplinary team to effect timely and appropriate patient management.
- Proactively identifies and resolves delays and obstacles to discharge.
- Collaborates with the interdisciplinary care team facilitating care for the designated case load; monitors the patient’s progress with the appropriate interventions ensuring a focused plan of care and services are provided while providing high-quality cost-effective care.
- Facilitates transfers to other facilities as appropriate.
- Provides the appropriate patient follow up in compliance with regulatory agencies and hospital policies and standards.
- Utilization Management:
- Identifies at-risk populations using approved screening tool and follows established reporting procedures.
- Monitors and facilitates the length of stay and ancillary resource use. Takes the appropriate actions to achieve the continuous improvement in both length of stay and resource utilization.
- Self-directed and organized to meet the needs of the patient and the health care team.
- Provides clear, concise, and timely written documentation.
- Communicate and provide information to post-acute care providers and payers ensuring adequate resources are provided to the patient.
- Communicates effectively and navigating conflicts with patients, families, members of the care team in a diplomatic and empathetic manner.Negotiation with clinical departments and payers, advocating for the patient; transitioning them to the next phase of care.
|Specialized Knowledge and Skills||
Sparrow Health System is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veteran status.
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