- Support patients with high-risk health conditions to navigate the healthcare system. Empower patients through patient education, providing resources, and advocating for patients and families to ensure a maximum quality of life.
- Interact and collaborate with the multidisciplinary care team, to include physicians, nurses, pharmacists, laboratory technicians, social workers, supportive care team, and other educators.
- Serve as a resource for clinic staff.
- Support longitudinal care of the patient with chronic conditions by:
Performing an assessment of health conditions.
Performing medication reconciliation.
Conducting Motivational Interviewing and Self-Management Goal setting.
Providing patient education, creating referrals to appropriate agencies and resources.
- Support transition of the patient with chronic care conditions from inpatient to outpatient by:
Performing assessment of transitional needs
Performing medication reconciliation
Establishing and reviewing action/contingency plans
Providing patient education
Assisting with post-discharge needs such as prescriptions, transportation, Durable Medical Equipment (DME), and appointments.
- Coordinate with providers to establish or update plan of care.
- Perform accurate and timely documentation in the electronic medical records.
- Participate in daily huddles and Patient Care Coordination (PCC) meetings.
- Prepare accurate and timely reports, as required, for weekly meetings.
- Maintain continued competence in nursing practice and knowledge of current evidence-based practices.
- Facilitate weekly PCC meetings.
- Actively participate in Nurse Case Manager meetings and offer suggestions for optimal care management.
- Track, follow, and coordinate ED and inpatient admissions, provide daily updates to providers, schedule for transitional visit, and submit required documentation to insurance portals.
- Developed a system for finding patients admitted to the hospital or ED, tracking them while in the hospital, coordinating care after discharge, and ensuring proper documentation submission to insurance portals occurs.
- Evaluated patient progress and adjusted care plans accordingly, ensuring continuity of care across all healthcare settings.
- Collaborated with physicians and other healthcare providers to ensure appropriate resource utilization for complex cases.
- Provided education and support to patients and families, empowering them to make informed decisions regarding their healthcare needs.
- Improved patient outcomes by consistently providing comprehensive assessments and developing tailored care plans.
- Evaluated healthcare needs, goals for treatment, and available resources of each patient and connected to optimal providers and care.
- Streamlined care coordination processes to reduce hospital readmissions and emergency department visits.
- Conducted comprehensive assessments of patients'' physical, emotional, and social needs in order to develop individualized care plans that facilitated optimal health outcomes.
- Responded promptly and professionally to patient questions and concerns.
- Effectively communicated with physicians regarding patient needs, performance, medications and changes.
- Participated in ongoing professional development opportunities focused on refining case management skills in alignment with industry bestpractices.
- Authored clinical notes and updates to be reviewed by patient's primary physician.
- Administered medications and treatments as prescribed by physicians.
- Completed initial assessments of patients and family to determine and address individual home care needs. ·
- Conducted regular re-evaluations to address changes in needs and conditions, introducing revisions to care plans.
- Developed professional relationships with community partners to enhance available support services for patients transitioning from acute care settings.
- Maintained detailed documentation of patient encounters, supporting accurate billing practices and data-driven decision making.
- Provided timely feedback to healthcare providers regarding patient concerns, facilitating prompt resolution of issues and contributing to a positive patient experience.
- Led process improvement initiatives aimed at enhancing efficiency in case management operations while maintaining excellent clinical outcomes.
- Reduced unnecessary medical interventions by monitoring high-risk patients closely, intervening as needed based on clinical expertise.
- Mentored new nursing professionals during orientation periods, fostering a collaborative team dynamic that supported the delivery of high-quality care.
- Conducted regular audits of clinical records to identify areas for improvement in documentation accuracy and compliance with regulatory standards.
- Educated patients and caregivers on healthcare protocols and processes.
- Educated family members and caregivers on patient care instructions.
- Communicated with healthcare team members to plan, implement and enhance treatment strategies.
- Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
- Evaluated patient histories, complaints, and current symptoms.
- Managed patients recovering from medical or surgical procedures.
- Equipped patients with tools and knowledge needed for speedy and sustained recovery.
- Collaborated with leadership to devise initiatives for improving nursing satisfaction, retention and morale.