RN-Recovery Care Coor (Remote) - Amedisys

Facilitates communication and coordination between all members of the care team.

Assists all patients throughout the care model by acting as a patient advocate and navigator .

Connect s with providers and patients regularly via a telehealth platform and receive s regular updates on patient activity that include vital signs and assessments.

Coordinate s referrals and appropriate resources to assist patient and/or caregiver in continuation of care in the outpatient setting.

Assists in the tracking and prioritization of high-risk patients and ensures patients have access to services appropriate to meet their needs.

Maintains all required documentation on provider and patient interactions including visits, intake, interventions, patient issues and any other elements of the patient's individual plan of care.

Generates operational, clinical, and quality reports and presents market updates on a regular basis.

Manages clinical and operational workflows.

Provides prompt, courteous, excellent service to internal and external customers at all times.

Interacts with the patient and the multidisciplinary team to evaluate and document measurable health care goals. Communicates to the appropriate providers any patient environmental barriers to the adherence of the c are p lan.

Communicates discharge information to other clinical departments or members of the c are t eam.

Watches for trends and hurdles involved in health care system and incorporates solutions for system challenges, including patient, family and physician responses into an evolving process and model that increases quality and satisfaction with the care experience - patient or physician.

Builds and maintains collaborative professional working relationships with physicians, m edical d irectors, clinicians and community at large to develop and implement a successful cross-continuum care management.

Monitors the care that the patient receives and brings it to the attention of a provider .