Role: As-needed Care Manager responsible for coordinating patient care across the continuum to ensure safe transitions, appropriate resource use, and strong patient advocacy.
Key Responsibilities:
- Conduct clinical and psychosocial assessments.
- Develop individualized care plans based on patient needs.
- Coordinate and collaborate with physicians, nurses, social workers, and community partners to optimize outcomes.
- Educate patients and families and support informed decision-making.
- Arrange post-acute services and resources.
- Identify and address barriers to care.
- Support complex discharge planning and ensure safe transitions of care.
- Document care coordination and clinical findings thoroughly in the EMR.
Qualifications/Skills: Strong assessment, care coordination, patient advocacy, communication, and documentation skills with a patient-centered, compassionate approach.