Job Description
What you will be doing:
Perform comprehensive patient assessments including clinical, psychosocial, environmental, and discharge planning needs
Develop and implement individualized care plans in collaboration with interdisciplinary teams
Coordinate transitions between acute care, rehabilitation, home health, long-term care, and community services
Facilitate discharge planning and identify barriers to safe discharge
Collaborate with physicians, therapists, social workers, and healthcare teams to ensure continuity of care
Advocate for patients and families while navigating complex healthcare systems
Assist with insurance authorizations and utilization review processes
Educate patients and families regarding treatment plans, resources, and post-discharge care
Connect patients with community programs and support servi...