- Assesses, analyzes, synthesizes data gathered and develops an initial discharge plan.
- Collaborates/communicates with the multidisciplinary care team throughout the continuum of care.
- Ensures appropriate utilization management by analyzing and synthesizing clinical documentation, and collaborating with the multidisciplinary team to ensure patients are receiving the right care, in the right place at the most appropriate level of care.
- Establishes the patient/family/case manager relationship and determines their readiness to engage in the discharge planning process.
- Maintains a working relationship with ancillary departments, external case managers and post-acute care providers.
- Screens / identifies patients that may benefit from professional case management services.
- Uses critical thinking to formulate and carry out a discharge plan according to the patient’s needs.
- Utilizes the Electronic Health Record to ensure timely, accurate and complete documentation of assessments, referrals, and variances in care.
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