Employment Type:

Full time

Shift:

Description:

GENERAL SUMMARY:

Develops, coordinates and oversees the implementation of patient specific plan of care. Works collaboratively with physicians, staff, and other health care professionals/agencies to negotiate care coordination across the health care continuum for disease specific populations. Communicates feedback about progress towards client goals with appropriate individual/groups at specific intervals. Collaborates with other services and disciplines, and when appropriate, the client’s medical physician and/or related health care professionals/agencies to enhance a holistic approach to patient care. Ensures safety, best practice, and high quality standards of care are maintained across the continuum. Is accountable for Care Management evaluation including: data capture and analysis, outcome achievement, and fiscal responsibility in an effort to improve service, quality and cost provided to the clients served.

ESSENTIAL FUNCTIONS:

· Completes a comprehensive assessment of the client’s holistic health status and needs to include clinical condition, support systems and resources, client/family knowledge, perception and adjustment towards disease process, and community resources.

· Screens patients/clients for identified and potential needs. Makes referral to appropriate multi-disciplinary services.

· Documents case management plan to include: assessment, client/family participation and understanding, consult referrals and discharge plan of care.

· Educates staff, clients/families, and medical community on care coordination and regulatory issues that impact care and outcomes.

· Documents clearly and timely in the Electronic Health Record and other required systems to insure effective communications along the continuum.

· Collaborates with Utilization Management staff regarding payer information, level of care and status determinations for patients.

· Understands and self manages to

We care about your well-being, both physical and mental, which is why our benefit package includes:

• Wellness programs

• Education reimbursement

• Personalized health insurance plans including dental and vision

• Paid time off

• Long- and short-term leave

• Retirement planning

• Life insurance coverage

Our Commitment to Diversity and Inclusion

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

EOE including disability/veteran