Overview

Responsible for providing patient case management services to assigned populations. They use a collaborative interdisciplinary approach to anticipate, integrate, and coordinate the patient's care plan, discharge plan, and reentry into the community. The primary goal is to meet patients' needs to optimize clinical and resource outcomes while monitoring the plan's effectiveness. In collaboration with the clinical team, identifies patients who would benefit from case management services. They perform assessments to identify patient needs and barriers, assisting in the development of the care plan. Acting as a patient and family advocate, serves as a communication link between the physician, patient, family, healthcare team, community resources, and payers to reduce redundancy and fragmentation of care. They anticipate potential delays in the healthcare process and proactively work to avoid these delays. Ensures that patients are provided with the most appropriate level of care at discharge while coordinating a smooth transition based on patient choice and availability.
Department Description


Licensure

Not Applicable
Education

Master's Degree Social Work Required
Experience

No Experience Required

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