
Assist in the development, implementation, and evaluation of a multidisciplinary, individualized patient plan of care that includes an appropriate transition plan.
Communicate with physicians, patients, families, and other members of the healthcare team to coordinate transition planning.
Work with physicians and other members of the healthcare team to ensure efficient utilization of multi-disciplinary resources.
Work collaboratively with physicians, nursing, multidisciplinary team, outpatient care management, Home Care and PCP offices.
Provided home health intake services, collaborating with inpatient care managers, home health branch offices, PCP offices and insurance providers to provide timely home health admission and facilitate hospital discharge.
Educated patients and families about home care services.
Obtained prior authorizations from insurance providers when appropriate.
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Microsoft Teams
Microsoft Excel
Epic
Careport Care Management
Certified Pediatric Nurse