||Patient Care Coordinator (Transitional)
|Date of Vacancy:
||Open until filled
for coordination of care transitions of MRC Health Services patients from Hospital,
Skilled Nursing and Rehabilitation facilities to home, ensuring excellent
communication between care partners.
Acts as liaison between hospitalist, patient, primary care provider, and
other care partners.
- Perform comprehensive patient assessments upon entry to service, identifying discharge needs and potential barriers.
- Develop and implement individualized patient care plan with a focus on disease management and patient empowerment.
- Assist patient and family with navigation of their health care system.
- Assist patient and family to access available community resources as appropriate.
- Maintain contact with the patients assigned PCP Patient Care Advocate.
- Participates as an active member of the patients' in-patient care team collaborating with patient, family, providers, site staff and other care partners.
- Identifies and reduces barriers to care utilizing organization and community resources as appropriate.
- Document all encounters and patient related discussions, telephonic or in-person, in the patient medical record per organization standards.
- Develop a listing of community resources and programs and how to access the same.
- RN with a minimum 5 years of clinical experience in both inpatient and ambulatory care settings.
- Minimum 4 years experience in Care Coordination, Case Management, or related area.
- Experience in Chronic Care Management desirable
- Case Management or related Certification desirable
- Experience in complex discharge planning preferred.
- Proficient in Microsoft Office products, EPM, and EHR software preferred.
- Ability to function autonomously while keeping team members and leaders informed.
- Possession of a current Florida State drivers license and a registered, insured vehicle as periodic travel may be required to effectively service clients.
**There are two shifts for this position: Tuesday - Saturday / Sunday - Thursday**
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