- Nuvance Health (Danbury, CT)
- …successful outcomes. Simultaneously, they drive the development and implementation of evidence-based care pathways, enhancing care transitions and optimizing ... * *Post-Acute Care Coordination:* Collaborate with post-acute care providers to ensure smooth transitions of...with post-acute care providers to ensure smooth transitions of care , prevent readmissions, and optimize… more
- Community Health Systems (Springdale, AR)
- …Skills and Abilities** + Demonstrates strong knowledge of pre-acute and post-acute care resources, care transitions , and healthcare utilization management. ... responsibly managing Medicare resources. The CCC is responsible for managing patient transitions between hospitals, clinics, and post-acute care providers. They… more
- Bon Secours Mercy Health (Mechanicsville, VA)
- …be utilized at points of level of care change, staff change, as well as care transitions . + Documentation will reflect plan of care to address post ... coordination of care for patients to support safe, seamless, timely transitions across the continuum. This role utilizes a collaborative process, the RN … more
- UPMC (Seneca, PA)
- …patient needs. + Provides clear, detailed guidance to patients and families for care transitions . + Applies adult learning principles to educate patients, ... care and outcomes. + Adapts to change with flexibility, supporting transitions to improve care and the work environment + RN license (or Temporary Practice… more
- Commonwealth Care Alliance (Boston, MA)
- …in case review meetings and rounds as needed to enhance coordination and care transitions . * Support the identification and implementation of innovative provider ... care - from inpatient to community-based - to improve transitions and continuity of care . Collaboration and Internal Coordination * Work closely with the… more
- UNC Health Care (Chapel Hill, NC)
- … to ensure a holistic approach. Plans should facilitate optimal patient care transitions to avoid unnecessary hospitalizations or emergency department ... families on available resources. Coordinates and delivers patient education, referrals, and transitions of care , including referrals for home health, hospice,… more
- AdventHealth (Shawnee, KS)
- …a variety of special assistance programs and agencies, and/or require assistance with transitions of care or discharge planning. In addition, offer crisis ... transition of care plans and initiation of the implementation of the transitions of care plans prior to the discharge of the patient. The Social Work Care… more
- AdventHealth (Bolingbrook, IL)
- …a variety of special assistance programs and agencies, and/or require assistance with transitions of care or discharge planning. In addition, offer crisis ... transition of care plans and initiation of the implementation of the transitions of care plans prior to the discharge of the patient. The Social Work Care… more
- Nuvance Health (Danbury, CT)
- …2. Collaborates with the medical team to formulate a treatment plan to include care transitions and promote patient flow. 3. Completes an initial assessment of ... needed from the team to facilitate the plan. 9. Facilitates smooth care transitions by ensuring appropriate clinical follow-up is arranged and referrals to… more
- Baystate Health (Springfield, MA)
- …for the management of care for a defined group of patients including complex care management, transitions of care , as well as coordination of care ... management utilizing multiple sources including physician referrals, referrals from transitions of care , health plans as well as complex lists of patients from… more