Temp - RN - Home Health; K ne ohe

Provides excellent patient care by assisting in collaboration, development, implementation, revision and reporting of the case management program. Acts as a liaison between the patient, family, nurse, physicians, multidisciplinary team and patient's healthcare benefactor to optimize outcomes. Serves as a consultant to the healthcare team on specific patient items.

• Leads the coordination of patient care with other disciplines within the care team, monitoring the appropriateness and timeliness of care.
• Ensures the interdisciplinary care plan is consistent with the patient s clinical course, continuing care needs and covered services by monitoring diagnostic testing, treatments and procedures, and other aspects of patient care as appropriate for acute care.
• Discusses with physicians, the appropriateness of resource utilization, consultations, treatment plan, estimated length of stay and discharge plan.
• Focuses on complex patients, frequent emergency department utilizers, chronic pain and substance abuse patients, and homeless patients.
• Collaborates with acute care case managers to ensure appropriateness on ongoing care.
• Coordinates the transfer of patients to tertiary centers, including the transfer of patient information required for continuity of ongoing treatment and services.
• Provides oversight and collects data required for regulatory/accreditation compliance.
• Manages frequent emergency department visitors by conducting a focus study review of the previous and current admissions.