Primary Duties and Functions:
Act as primary point of contact for eligible patients utilizing select Fort Hudson programs following hospitalization during service period.
Collaborate with care providers in acute and post-acute settings to assure seamless transitions of care, coordinated service planning, and active engagement with care management services in the community
Conduct on-site or in-home visits of eligible patients during post-acute treatment periods at specified intervals to support continuity and communication
Conduct in-hospital visits during an rehospitalization or as otherwise indicated of eligible patients
Maintain detailed data and roster reports; identify additional data points as indicated which support the improved care outcome goals
Minimum of 2 years’ experience as a Registered Nurse required. One or more years experience as RN in home care setting preferred. Prior relevant experience in care management or similar role; experience in linking services and programs for community-based services to support individual’s independence in the community.
Must have valid NYS driver’s license; free of disqualifying offenses; reliable transportation capable of traveling in excess of two (2) hours at a time.