Oversees chronic care and transitions of care management of high-risk patients within their care teams and neighborhood centers. 

Serves as a resource to the multidisciplinary team for the management of complex patients, including chronic care management assessments and care plans. 

Performs triage for patients via phone and addresses issues appropriately or forwards message to appropriate party for further interventions. 

Responsible for ensuring efficient, organized patient transitions from acute and post-acute setting to home or other transitional care facility. 

Perform comprehensive assessments for both physical, mental, and social risk factors that support individual patient needs while identifying and addressing barriers.  

Collaborates with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting. 

Coordinates/facilitates patient care progression throughout the continuum.  

Collaborates with the physician and all members of the multidisciplinary team to facilitate care for designated patients; monitors the patient’s progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective; facilitates the following on a timely basis: completion and reporting diagnostic testing, treatment plan and discharge plan; modification of plan of care, as necessary, to meet the ongoing needs of the patient; communicates relative information to the care team; assignment of appropriate levels of care; completion of all required documentation.

Coordinates and communicates with providers and all involved care team members in the discharge plan to ensure their participation and readiness. 

Ensures that all elements critical to the plan of care, including discharge plans, have been communicated to the patient/family and members of the healthcare team and are documented as necessary to assure continuity of care. 

Knowledgeable of the Four Elements of the Coleman Model 

Coordinates post-discharge needs with providers, such as Durable Medical Equipment, Home Health needs, medications, and other supplies. 

Proactively identifies/resolves issues impeding diagnostic, treatment progress, and discharge.  

Schedules patient for follow up with PCP or specialist within 7 days of discharge. 

Reconciles discharge medication and works with PCP and clinical pharmacist for review post-discharge. 

Reviews and evaluates patient to ensure that the patient meets criteria for home health admission or admission to other transitional care institutions. 

Tracks and monitors readmissions to acute care facilities and assists with re-hospitalization reduction initiatives. 

Works with clinical team to establish care programs to help prevent readmissions and hospitalizations. 

Obtains patient medical records from acute care facilities, including orders, referrals, care team documentation, diagnostic testing results, and acute care visit summaries. 

Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues.  

Identifies at-risk populations using approved screening tool and follows established reporting procedures. 

Refers cases, issues to clinical leadership team, and follows up as indicated.  

Refers appropriate cases for social work intervention as needed. 

Collaborates/communicates with external case managers. Initiates and facilitates referrals for home health care, hospice, medical equipment, and supplies. 

Actively participates in clinical performance improvement activities. 

Uses data to drive decisions and plan/implement performance improvement strategies related to case management for assigned patients, including fiscal, clinical, and patient satisfaction data. 

Collects, analyzes, and addresses variances from the plan of care with multidisciplinary care team. 

Documents assessments, phone calls, and patient interactions in the Electronic Medical Record promptly. 

Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency. 

Other duties as assigned that are within the nurse’s scope of practice.