Role Summary: Coordinates skilled nursing and long-term care services for patients in contracted facilities. Partners with physicians and multidisciplinary teams to develop individualized care plans, monitor patient progress, and support appropriate levels of care. Ensures continuity of care through safe and effective discharge planning and manages care transitions.
Key Responsibilities:
- Coordinate patient care across contracted skilled nursing/long-term care settings
- Collaborate with physicians and multidisciplinary teams to create and update care plans
- Monitor clinical progress and respond to changing patient needs
- Support appropriate utilization and recommend appropriate care levels
- Manage referrals and coordinate handoffs between care settings
- Provide patient and caregiver education to support understanding and adherence
- Ensure safe discharge and smooth transitions to next steps in care
Required Skills/Qualifications: Clinical care coordination, strong collaboration and communication, care plan development, utilization/referral management, and discharge planning focused on patient safety.