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The RN supports professional nursing practice across practice settings and across the continuum of care to meet the needs of the patient and family. The registered nurse (RN) is accountable for the coordination of nursing care, including direct patient care, patient/family education and transitions of care.
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Manages outcomes for wound, ostomy and continence patients across the continuum of care by providing, coordinating, and supporting clinical aspects of direct patient care including appropriate discharge planning, and coordination of services and education.
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Provides consultation to medical providers, other CBHC staff, and other service providers to facilitate a coordinated continuum of care. Case Management services are made available to primary care, obstetrics/gynecological, pediatric, dental, behavioral health, LHRC, and infectious disease patients, who present with 1) general level of needs requiring routine follow-up and monitoring; 2) specialized or targeted needs requiring a specific, responsive, skilled intervention; or 3) complex needs and requiring moderately intensive monitoring and follow-up services.
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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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In collaboration with the licensed care manager or designee, the Health Coach will partner with patients to ensure improved access to, and coordination of, clinical and community services across the continuum of care.
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The Neuroscience Coordinator (Stroke Coordinator) is responsible for the coordination and maintenance of a comprehensive Neuroscience/Stroke program that complies with National standards for quality of care for neuro/stroke patients as dictated by the American Heart Association (AHA), and stroke programs that meet or exceed recommendations of regulatory agencies such as ACHC/The Joint Commission, governmental regulation for Medicare Compliance, and established evidence based best practices.
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The Hospital Social Worker is an exciting opportunity at MultiCare, responsible for cross continuum care coordination, psychosocial assessments, and psychosocial interventions. You will perform cross continuum care activities, which may include clinic, provider practice, urgent care, phone care agency, skilled care, or other sites of care, as appropriate.
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Provide continuum of care/follow up care to patients. Provide detailed communication to receptive discharge providers to ensure warm handoff in the care coordination process.
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We are searching for a Patient Access Representative – Rehab to perform a variety of office support, coordination of various patient care processes and other related duties in accordance with established Rehabilitation Services department policies and procedures.
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Knowledge of care delivery systems across the continuum of care including, but not limited to, trends and issues in care reimbursement, medical necessity and assigning level of care assignment (inpt vs obs.
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The RN Case Manager is responsible to facilitate care along a continuum through effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient's resources and right to self-determination.
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Two (2) years care coordination to include one year of bedside nursing experience required; case management, chronic disease management, population health, or managed care experience preferred.
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Performs professional nursing duties that incorporate the psychosocial, psychomotor and age appropriate cognitive skills of the patient/family/significant other to assess, plan, intervene and advocate for the patient on an ongoing basis throughout the continuum of care.
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Care and Service Coordination: Practices as an effective member of the patient care team. Patient Relationship: Develops and maintains a restorative relationship throughout the healthcare continuum, following Advocate's MVP of Compassion.
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Serves members throughout the care continuum requires the WOCN to travel among Kaiser Permanente Medical Centers and/or core Hospitals and SNFs, as well as monitors clinical progress in Home Wound Care.
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continuum of care coordination jobs
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