Provides support for care transition activities, facilitates transitional care processes, and coordinates for member discharge from hospital admission to all other settings, with the goal of reducing member readmissions.
Requirements
- Follows member throughout a 30 day program that starts at hospital admission and continues oversight through transitions from acute setting to all other settings.
- Ensures safe and appropriate transitions by collaborating with the hospital discharge planner, as well as collaborating with hospitalists, outpatient providers, facility staff, and family/support network.
- Conducts face-to-face visits of all members while in the hospital and, home visits high-risk members post-discharge as needed.
Benefits
- Competitive benefits package
- Equal Opportunity Employer (EOE) M/F/D/V