- UNC Health Care (Raleigh, NC)
- …discharges, readmissions, and social needs. The role involves leading or supporting transition -of- care planning for high-utilizer, high-risk, or medically ... integrating and functions of case management, utilization review and discharge planning . The Care Manager...to community resources and post-acute providers as necessary. 5. Care Progression and Transition Planning … more
- UNC Health Care (Raleigh, NC)
- …effectiveness through the integrating and functions of case management, utilization review and discharge planning . The Care Manager must be highly organized ... to community resources and post-acute providers as necessary. 5. Care Progression and Transition Planning ... discharge based on experience, Communication and Patient Planning (CAPP) Meetings and/or Complex Care Meeting… more
- Rush University Medical Center (Chicago, IL)
- …of complications. * Identifies variances related to length of stay, readmissions, and the discharge / care transition planning process across the continuum ... Nurse Leader (CNL) functions as an advanced generalist providing and managing care for patients, individuals, families, and communities in the microsystem. The CNL… more
- AdventHealth (Hinsdale, IL)
- …Manager communicates daily with the interdisciplinary team during daily multidisciplinary rounds. Care coordination, discharge planning , transitions of ... to utilization of resources, medical necessity, CMS CoP for Discharge Planning and care coordination....goals and preferences as much as possible into the transition of care planning and… more
- Houston Methodist (Nassau Bay, TX)
- …picture of the patient for opportunities for care facilitation and needs for discharge planning . Works with case manager for routine discharge and ... goals with patient and family, providing appropriate resources, incorporating planning for care after discharge ....concerning safety data to improve outcomes and the safe transition of care through effective patient handoffs.… more
- AdventHealth (Winter Garden, FL)
- …Manager communicates daily with the interdisciplinary team during daily multidisciplinary rounds. Care coordination, discharge planning , transitions of ... to utilization of resources, medical necessity, CMS CoP for Discharge Planning and care coordination....goals and preferences as much as possible into the transition of care planning and… more
- AdventHealth (Altamonte Springs, FL)
- …Manager communicates daily with the interdisciplinary team during daily multidisciplinary rounds. Care coordination, discharge planning , transitions of ... to utilization of resources, medical necessity, CMS CoP for Discharge Planning and care coordination....goals and preferences as much as possible into the transition of care planning and… more
- Minnesota Visiting Nurse Agency (Minneapolis, MN)
- …caseload for continuing service/treatment and provide care coordination including discharge / transition planning * Interpret and explain policies, ... treatment planning * Documents psychosocial assessment, progress notes, telephone calls, care plans and discharge / transition plan in the electronic… more
- Hartford HealthCare (Southington, CT)
- …of discharge plan and orders in conjunction with discharge planning staff to ensure a smooth transition home. Follow Up Case Coordination/Social ... level of care to another to ensure a safe and effective patient's transition across the post-acute care continuum. Serves as a bridge between the healthcare… more
- Covenant Health Inc. (Knoxville, TN)
- …Conditions, Hospital Acquired Infections and proactively initiates actions to prevent same Discharge / Transition Planning : + When necessary, serves as the ... the patient/ care giver transition of care needs and facilitating a safe discharge ....with other facilities, services and departments involved in Interdisciplinary Discharge Planning Rounds. General Duties: + Serves… more