Job Summary:

• Identify and coordinate patient care needs in anticipation of the next site of care after hospitalization. 
• Provide guidance for clinical coordination, and collaboration among multidisciplinary caregivers.
• Complete comprehensive psychosocial assessment and review of clinical needs of patients
• Collaborate with physicians, social workers and other disciplines involved with care of the patient to foster a coordinated approach to discharge planning
• Identify and navigates patient testing and treatment to reduce barriers to patient discharge and preventing delays in patient care
• Communicates barriers to leadership for resolution and trending
• Effective use of time management skills to multitask, manage relationships with post-acute providers and gather resources for the department.
• Working knowledge of federal, state and local laws that govern health care and case management.

Skills on Resume:

• Care Coordination (Hard Skills)
• Team Collaboration (Soft Skills)
• Psychosocial Assessment (Hard Skills)
• Discharge Planning (Hard Skills)
• Barrier Navigation (Soft Skills)
• Effective Communication (Soft Skills)
• Time Management (Soft Skills)
• Regulatory Knowledge (Hard Skills)

Job Summary:

• Provide continuity of care, promote cost containment, enhance quality, and improve clinical and financial outcomes.
• Use clinical expertise to conduct telephonic health assessments
• Provide appropriate education and clinical interventions to members in multiple disease populations.
• Develop meaningful relationships with members and/or their caregivers functioning as a resource and advocate to enhance quality of care.
• Certain positions may require additional certifications and/or specialized training based on assigned patient population.
• Responsible for providing care management services to beneficiaries with planned admissions to acute care hospitals
• Systematically identifies and addresses fragmented care for patients with acute, real-time needs 
• Tailors interventions and services to fill gaps and produce optimal clinical outcomes cost-effective
• Assume responsibility for professional growth and development
• Active participation in continuing education, in-service programs, orientation and personal evaluation.

Skills on Resume:

• Care Continuity (Hard Skills)
• Health Assessments (Hard Skills)
• Clinical Education (Hard Skills)
• Relationship Building (Soft Skills)
• Certification Knowledge (Hard Skills)
• Care Management (Hard Skills)
• Care Coordination (Hard Skills)
• Outcome Optimization (Hard Skills)

Job Summary:

• Provide quality, professional nursing care.
• Maintain a safe environment for patients.
• Promote health counseling for the patient and the family.
• Conduct a comprehensive patient assessment, plan and implement patient care.
• Document changes in the individualized patient Care Plan and make appropriate notes in the patient’s clinical records.
• Initiate preventative and rehabilitative nursing procedures and techniques.
• Initiate appropriate communication with the Physician and Director of Nursing and other disciplines to provide comprehensive care.
• Perform therapeutic procedures as prescribed by the physician.
• Supervise auxiliary personnel and delegate responsibilities
• Work with families and other health care professionals in providing continuity of patient care.

Skills on Resume:

• Nursing Care (Hard Skills)
• Safety Management (Hard Skills)
• Health Counseling (Hard Skills)
• Patient Assessment (Hard Skills)
• Clinical Documentation (Hard Skills)
• Rehabilitative Procedures (Hard Skills)
• Interdisciplinary Communication (Soft Skills)
• Supervisory Skills (Soft Skills)

Job Summary:

• Work patiently and diligently with diverse and high-needs clientele.
• Demonstrate integrity and transparency in this autonomous role.
• Work independently with little supervision and contribute positively to small team of 7 employees in the office.
• Adhere to policies, procedures and guidelines.
• Provide excellent customer service both internally and externally.
• Utilize excel for each client to enter financial details, payee information and budget tracking.
• Enter case notes into proprietary software and demonstrate diligence in keeping up with data entry.
• Assists clients who can get housing within the 30 day period.
• Connecting clients with services such as employment assistance, education, training, physical/mental/chemical health services, child care, transportation or legal services.
• Work with landlords who are willing to assist clients with housing
• Working out details of rent payments, deposits, and/or application fees.

Skills on Resume:

• Client Diversity (Soft Skills)
• Integrity (Soft Skills)
• Independent Work (Soft Skills)
• Policy Adherence (Hard Skills)
• Customer Service (Soft Skills)
• Excel Proficiency (Hard Skills)
• Data Entry (Hard Skills)
• Service Coordination (Soft Skills)