Supports the Case Manager in facilitating and coordinating the transition of the patient’s plan of care from one healthcare environment to another, or home, based on their need for continued care.
It includes a systematic process of: assessing appropriateness, including the level of care and continued stay of the patient during hospitalization planning for continuity of health care upon discharge from hospital, and coordinating needed individual, family, hospital and resources to implement the discharge plan.
Incumbent has the responsibility to support the Case Manager to facilitate and coordinate the assessment, planning, implementation, intervention and evaluation of the options and services available to meet the patients healthcare needs across an episode or continuum of care. Facilitates patient wellness and autonomy through advocacy, assessment, planning, communicating, education, and resource management within a multidisciplinary team.
Actively works to eliminate barriers to the delivery of clinical services with the patient, family and healthcare team and monitors clinical resource utilization.
Creates a discharge plan appropriate to the patients needs and resources. Based on the individual needs and values of the patient and in collaboration with all service providers the care manager connects patients with appropriate healthcare providers and human services and care settings, whilst ensuring that the care provided is safe, effective, patient centered, timely, efficient and equitable. This approach achieves optimum value and desired outcomes for the patient / families, healthcare providers and the organization: reduce length of hospital stay and reduce re-admission rate.
Work hours are assigned to meet operational needs. Hours may include on call and scheduled overtime.
Direction is through the unit manager.
Contact with unit personnel, nursing managers, Nursing Shift Coordinator, Social Workers, Pharmacists, Rehabilitation staff, Clinicians at all levels, Patient and Family members, Medical Customer Services Network, and other Johns Hopkins Aramco Healthcare personnel involved in the care of the patient.
PATIENT CARE:
PROFESSIONAL EXPECTATIONS
3 years International Diploma or Bachelor Degree.
5 years minimum clinical nursing experience following licensure/registration in the country of origin, to include 2 years Case Manager experience.
. Current licensure as a professional registered nurse.
. Case Management Certification is desirable or additional years experience in lieu of formal course and
. Advanced training/certification in specialty is required.
. Fluent spoken and written English. Spoken Arabic desirable.
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