Summary: Responsible for partnering with the physician and multidisciplinary team in coordinating patient care with the underlying objective of enhancing quality and cost effective care. Acts as a resource and patient advocate to facilitate a safe transition across the continuum. Position Responsibilities: Care Coordination – completes appropriate assessments and plans effectively to meet patient needs, monitors the length of stay and promotes efficient utilization of resources. Acts as a clinical expert and maintains ongoing knowledge of clinical practice guidelines. Engages the physician and builds seamless continuity of care and is the physicians single consistent resource. Problem resolution, patient/family communication. Helps identify factors impeding patient progression, resolves, escalates and documents as appropriate. Refers appropriate cases for Social Work intervention. Documentation – Appropriate and complete documentation of individual plan of care in EMR and case management documentation system. Metrics- Accountable to job specific goals, objectives and dashboards which contribute to the success of the organization. Participates in organizational improvement activities including patient satisfaction, Six Sigma committee, department and/or divisional teams and community activities. Compliance – understands and applies applicable federal and state requirement. Identify and reports compliance issues as appropriate. Position Qualifications Required: Required Experience: Minimum 3 years clinical nursing (RN) experience or Social Work Minimum of 1 year Case Management or other interdisciplinary experience including Homecare Coordination in an Acute Care setting or behavioral health in an inpatient outpatient or integrated behavioral health setting; understanding of Medicare, Medicaid, managed care and discharge planning. (3-5 years preferred) Excellent verbal and written communication skills, problem solving, critical thinking and conflict resolution. Required Education: RN or Masters prepared Social Worker Training / Certification / Licensure: RN or LSW required; LCSW considered