RN - Case manager

Coordinate the overall interdisciplinary plan of care for patient, from admission to discharge
Create plan for care across the continuum, integrating patient/family preferences and values
Monitor patient medical necessity and level of care through assessments, ongoing evaluations and/or patient records
Advocate for resources and removal of barriers
Maintain ongoing dialog with supervisor and care transition team members to ensure effective implementation and reevaluation of health plan
Act as a resource for adequate medical record documentation, level of care recommendations, and services as they relate to diagnoses, and treatment options for post-discharge care