- SUNY Upstate Medical University (Syracuse, NY)
- Job Summary: The Transitional Complex Patient Specialist works collaboratively with Case Management, Social Work, the treatment team, as well as other ... at high risk for readmissions and unnecessary Emergency Department visits. The Transitional Complex Patient Specialist will work with patients through… more
- HonorHealth (Scottsdale, AZ)
- …LMSW - Transitional Case Manager identifies and monitors patients with complex disease states and provides patient /family education and direction. Working ... represents the total care needs and resources of the patient /client and family. The LMSW - Transitional ...with the PCP or specialist , the LMSW - Transitional Care Coordinator… more
- Brockton Hospital (Brockton, MA)
- …care team to integrate evidence based clinical guidelines in the development of patient centered care plans. Initiate TCM Visits: Transitional Care Management CM ... POSITION SUMMARY: Signature Medical Group is a NCQA recognized Patient Centered Medical Home (PCMH) organization. The model promotes primary care that is accessible,… more
- ProMedica Health System (Sylvania, OH)
- …appropriately; implements interventions according to risk score. 7. Identifies transitional care barriers and collaborates in comprehensive, patient -centered ... Position Summary: The RN Acute Care Navigator is responsible for direct patient care focusing on: Care Progression/Care Coordination, Level of Care, Length of Stay,… more
- WMCHealth (Suffern, NY)
- …care provided to specific patient populations, and engages team of transitional care specialist (s) and care coordination to divide workload among team ... self-care abilities, decrease cost of care, and provide extraordinary patient care in the process. The Ambulatory Care Manager...Care Managers can include but are not limited to: complex patients whose critical event or diagnosis require extensive… more
- AdventHealth (La Grange, IL)
- …to psychosocial needs, decision making needs for patients who lack capacity, patient /family adjustment needs and psychosocially complex cases. **.** Develops ... The Social Work Care Manager intervenes with patients who have complex psychosocial needs, require assistance with eligibility determination for social programs,… more
- AdventHealth (La Grange, IL)
- …to psychosocial needs, decision making needs for patients who lack capacity, patient /family adjustment needs and psychosocially complex cases. **.** Develops ... role you'll contribute:** The RN Care Manager in collaboration with the patient /family, social workers, nurses, physicians and the interdisciplinary team, ensures … more
- AdventHealth (Winter Garden, FL)
- …to psychosocial needs, decision making needs for patients who lack capacity, patient /family adjustment needs and psychosocially complex cases. + Develops ... role you'll contribute:** The RN Care Manager in collaboration with the patient /family, social workers, nurses, physicians, and the interdisciplinary team, ensures … more
- Health First (Melbourne, FL)
- …10. Intervenes and recommends appropriate referrals to resolve system barriers to patient discharge 11. Identifies and documents necessary transitional care ... of care and services for trauma patients in collaboration with the patient , family/caregiver, trauma surgeon/APP, and patient care team. The position… more
- The Mount Sinai Health System (New York, NY)
- …the myriad needs of the diverse populations we serve. We believe that total patient care must emphasize the physical, emotional, and social needs of each patient ... Health System's population health initiatives: programs of care that enhance the individual patient 's experience and health status, improve the health of patient … more