JOB SUMMARY:
Responsible for coordinating the continuum of care for high risk patients from time of ED presentation, during their hospitalization and post discharge. Provides education and support to patients, family, staff and caregivers. The goals of this position include improving patient care and flow, eliminating barriers and improving the overall patient experience by connecting the patient and family with appropriate resources and services.

FUNCTIONS OF THE JOB:

1. Assessment and Plan of Care: Assessment and development of an individualized plan of care through initial and periodic assessments and through communication with patient/family, physicians and other staff. Identifies physical, psychosocial, spiritual and social needs and coordinates the development and implementation of a plan of care to meet those needs effectively, efficiently and at the appropriate level of care required.
2. EMR Documentation: Documents all patient and physician interactions in the electronic medical record, including all education related encounters. Keeps the physician and care team informed of treatment goals and patient milestones.
3. Care Coordination: Coordinates the care of identified patients. Serves as a patient advocate and facilitates care coordination and collaboration with multidisciplinary team members. Focuses on patient satisfaction including timely testing and treatments and actively seeks ways to improve patient flow and mitigate readmissions.
4. Follow-up: Ensures follow-up with appropriate resources as identified during the patient's stay and documented in the plan of care.
5. Patient Education: Provides education to patients and families prior to initiating treatment that supplements and enhances the education that is given by the patient's physician. Provides individualized (to include language specific) educational tools that include written, video and/or face-to-face interactions with multidisciplinary team. Also responsible to review patient educational materials annually and make recommendations for changes or additions.
6. Communication and Multidisciplinary Management: Works closely with physicians as primary patient liaison to support the physician-patient relationship. Communicates and educates while coordinating patient care in an effective and timely manner (i.e. assist with appointment scheduling, medication needs, and education on specific treatments).
7. Data Collection: Assists with development of performance metrics to measure program success. Collects and analyzes outcome data, maintains statistics, records and resource files. Identifies areas of improvement and develops action plans accordingly. Expected to perform a root cause analysis on all readmissions, produce recommendations for improvement, and participate in proactive innovative solutions development.
8. Performs related duties as assigned.