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Serves as a patient/family advocate and acts as a communication link between physicians patients family health care team members and community resources to reduce redundancy and fragmentation of care.
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As part of the Recuperative Care Program (RCP) Team at the 40 Prado Homeless Services Center this position will work with up to 6 homeless individuals needing 24-hour supervision due to recent discharge from a participating hospital or skilled nursing facility.
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The activities will include daily review of hospital care by chart review and discussion with attending physician, admission and concurrent review for inpatient admissions, meetings with patient and families to develop discharge planning, identification of patients for ambulatory case management, communication with case managers, home care reviewers, social workers, members and providers, quality improvement reviews, and education of the member/family, provider and hospital staff.
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Demonstrated knowledge of case management, discharge planning, transition of care, transfer coordination; Medicare, Medicaid, Title 22, NCQA, JCAHO, URAC, and other federal/state/local regulations.
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RN Case Manager | Discharge Planner - Ambulatory Care. The Case Manager II will provide case management services to patients and their families or caregivers. The Professional Model of Care requires registered professional nurses to be responsible and accountable for their own practice.
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Discharge Planning assists with LTC, SNF, Rehabilitation, Behavioral/Mental Health, Home Care, DME, transportation and other placement planning needs. Effectively utilizes hospital resources in the development of care, discharge planning and Utilization Review.
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The case manager demonstrates the ability to assess, coordinate, plan, monitor, implement and evaluate the patient’s plan of care while ensuring and facilitating the achievement of optimal quality, clinical and financial outcomes.
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With involvement of the patient/family, collaborates with licensed practitioners and other inter-professional team members to provide care coordination, transitional care planning, facilitation and coordination of discharge needs.
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Role models the tenets of Mount Sinai Relationship Centered Care (MSHRCC) through facilitation of the following actions including, but not limited to, Admission Welcome, Bedside shift Report, HELP (High Risk Medications, Equipment, Lines/Drains/Airway, Pain and Plan of Care) AM/PM Care, 5 Minute Sit Down, Purposeful Hourly Rounding, Medication Review, Discharge Wrap Up, and MD/RN Unit Collaboration.
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Position Quality Review Nurse, RN Description Reporting to the Manager of Provider Quality Oversight, the Provider Quality Review Nurse, RN is responsible for: - Receive and research all PQI and QR cases as assigned, provide a summary and recommendations to the Medical Director of case assignments.
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Under close supervision, the Counselor/Discharge Planner position provides support and structure to participants in developing program plans by managing a caseload and administering the policies and procedures of the program as directed by the contracting agency and the Program Manager.
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Specific Job Duties/Responsibilities Provides high quality clinical services within the scope of practice and within infection control standards, in accordance with the plan of care/service plan, and in coordination with other members of the patient/client’s care team from admit through discharge.
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The CMA assists in the readies of the patient for discharge, participates in the communication to the patient and caregiver on the post-acute plan, assists with preference based on quality, leads the referral process and provides resources to patients as directed by the Care Manager.
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Assists with discharge arrangements for care facility and home discharge in collaboration with the RN Care Manager and/or Social Worker. Responsible for assistance with discharge arrangements for care facility and home discharge.
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Clinical skills including assessment, intervention, discharge, anticipation of needs, and data collection. Acts as an overall clinic leader with the Clinic Administrator and Medical Director, meeting regularly with both to improve Primary Care services.
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care manager discharge jobs
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