Essential Job Responsibilities/Expectations

1. Job responsibilities include those listed in competency document.

2. Maintains a professional image and exhibits excellent customer relations to patients, visitors, physicians, and co-

workers in accordance with our Service Excellence Standards and Core Values.

3. Serves as a liaison between the acute care facility and the community healthcare providers to ensure continuity of care

for patients based on social, economic, medical and emotional needs.

4. Serves as patient advocate to ED population by identifying needs, coordinating services and resources for the

management of complex patients to facilitate quality care and cost efficient outcomes.

5. Participates in community resource collaborative committees to set measurable goals for the community population and

to assure work towards all established program milestones.

6. Assists with the creation and support of evidence-based care protocols and education with participation and

collaboration with community stakeholders at committee meetings and one on one planning sessions.

7. Promotes individual professional growth and development by meeting requirements for mandatory/continuing education

and skills competency.

8. Works collaboratively with multiple disciplines and community facilities/resources to provide innovative and evidence-

based care while achieving high quality outcomes in a cost efficient manner.

9. Continuously identifies and connects appropriate patients to the programs such as Healthy Outcomes or others based on

eligibility, in order to utilize community-based resources that will help to facilitate care, addressing both urgent and

chronic needs.

10. Provides discharge planning and care coordination based on clinical standards to facilitate the delivery of cost effective

quality healthcare and assists in the identification of appropriate utilization of resources across the continuum of care.

11. Evaluates and assist with placement of patients presenting to the ED in acute mental health crisis.

12. Completes necessary documentation in the electronic health record and other care management software/databases for

effective reporting and analysis. Provides support and assessment of plan of care compliance, addresses barriers to care

and provides crisis intervention as necessary to patients between visits.

13. Uses health coaching strategies to develop, implement and evaluate self-management strategies for patients as well as

learning programs for patients and their families.

14. Assures appropriate use of acute hospital case management services and connection to community case management

services where appropriate and available to provide high quality care and achieve the Triple aim goals.

15. Participates in continuous quality improvement via team involvement and by supporting changes recommended through

the steering committee. Validates program effectiveness using established metrics and ongoing measurements to assure

program is meeting intended goals.

16. Ensures that all elements critical to the plan of care are developed by the community partners for the patient.

Educates patients and families on community resources, benefits and responsibilities.

Job Requirements

Qualifications/Training

• 1 - 2 years of recent acute care hospital experience required

• Data entry/computer experience required

Licenses/Certifications/Registrations/Education

• Registered Nurse from an NLN accredited school of nursing required

• Licensed RN to practice within the applicable region of employment and coverage area of responsibility is required

Physical Requirements: Refer to Occupational Risk Assessment

WORK SCHEDULE

Full time

JOB LOCATION

Florence, SC, United States

POSITION TYPE

Full time