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Care Manager RN
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Full-time
- Coordinates with the Primary Care Physician (PCP) and functions as part of an interdisciplinary team to guide high risk patients across care delivery sites, including inpatient, ambulatory and post-acute care settings.
- Ensures continuity of care through defined, evidence-based methods, including, but not limited to, medication reconciliation, self-management plan, engagement of family and care giver, health education and referrals.
- Participates in the development and execution of the Plan of Care across the continuum of care, including acute, post acute and home settings
- Demonstrates expertise in case management and serves as resource to the interdisciplinary health care team
- Works in collaboration with inpatient and ambulatory healthcare staff, as well as community resources as necessary to facilitate continuity of care
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