Provide comprehensive care coordination for Medicare Pioneer ACO patients in the skilled nursing facility (SNF) setting. Assess the patient’s plan of care and develops, implements, monitors and documents the utilization of resources and progress of the patient through their care, facilitating options and services to meet the patient’s health care needs. Intensity of care coordination provided is situational and appropriate based on patient need and payer requirements. Accountable for the quality of clinical services delivered by both them and others and identifies/resolves barriers which may hinder effective patient care

Provide clinical and financial concurrent review for patients in acute care setting. Assess and collaborate with patient and/or family to determine appropriate needs and/or placement. Develop and execute appropriate transition plan with assistance of case management team, physicians, nursing and ancillary staff. Communicate with in house UR team, payors and physicians medical necessity and plan of care. Coordinate with outpatient case managers, discharge planners and community agencies/facilities to provide appropriate resources to patients upon discharge out of the acute care settings.

Responsible for all appropriate clinical and administrative aspects in a National Institute of Health funded grant. Responsible for study-related documentation/communication to the Institutional Review Board and other project sites. Supervises activities of research team. Maintains and monitors integrity of data analysis. Assists Principal Investigator and project team in development of project presentation and manuscripts.

Responsible for enrollment and all appropriate clinical aspects for participating patients in assigned clinical trials. Responsible for study-related documentation/communication preparation of IRB submission of new protocols. Interfaces and communicates regularly with hospital departments, outside facilities and study sponsors.

Cardiac Care Unit Staff RNAMI Transport Team Staff RNCardiac Catheterization Laboratory Staff RN