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- Responsible to become a subject matter expert on Bedrock service offerings, disease specific clinical criteria and evidence based medicine.
- Works with facility team on a weekly basis to understand patient needs upon admission to hospital/skilled nursing and proactively sets up a discharge plan
- Facilitates conversions to Continuous Care Management/Patient Care Therapy Group/Patient Care Medical Group/Bedrock at Home
- Holds recurring Monthly partnership meeting with department heads to review wins/constructive action items
- Collaborate with medical professionals to assess patients' healthcare needs and coordinate the delivery of post-discharge services, including follow-up appointments, home healthcare, rehabilitation, and other necessary resources.
- Weekly touchpoints with Bedrock onsite physician team to review wins/obstacles of week to week care and assists in addressing these items with facility staff (if applicable)
- Provides referrals to partnered center
- Establish and maintain effective communication channels between patients, healthcare providers, and relevant stakeholders to ensure a smooth transition and continuity of care
- Joins social work/case management team in weekly patient care conferences
- Weekly meeting with admissions team to review each admission and the dynamics of the patient upon entering hospital/rehab
- Weekly meeting with social work team to review upcoming discharges and ensures a plan is in place in a proactive fashion
- Works with Bedrock Continuous Care Management team to develop outcomes report to be presented to facility leadership on a quarterly basis
- Provides monthly report on referral conversions/wins/challenges/plan for subsequent month to Bedrock leadership
- Maintain accurate and up-to-date records of patient interactions, care plans, and service arrangements to facilitate efficient and organized care coordination
- Resolves customer feedback by investigating opportunities for development, developing solutions, preparing reports, and collaborates on resolutions with program management
- Excellent presentation, negotiation and relationship-building skills
- Strong customer service, sense of urgency and problem solving skills
- Time management and organizational skill
- Attends all required training, in-services, and staff meetings.
- Strives to maintain a safe working environment through the prevention of accidents, the preservation of equipment, the achievement of safe working practices, by practicing proper infection control measures, and understanding the use of Material Safety Data Sheets (MSDS).
- Maintains a positive and professional demeanor toward residents, visitors, families, and co-workers.
- Adheres to all policies and procedures of Bedrock Healthcare at Home
- Performs all other duties as assigned.
- Active Listening - Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.
- Speaking - Talking to others to convey information effectively.
- Reading Comprehension - Understanding written sentences and paragraphs in work related documents.
- Critical Thinking - Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.
- Monitoring - Monitoring/Assessing performance of yourself, other individuals, or organizations to make improvements or take corrective action.
- Social Perceptiveness - Being aware of others' reactions and understanding why they react as they do.
- Problem Sensitivity - The ability to tell when something is wrong or is likely to go wrong. It does not involve solving the problem, only recognizing there is a problem.
- Oral Comprehension - The ability to listen to and understand information and ideas presented through spoken words and sentences.
- Oral Expression - The ability to communicate information and ideas in speaking so others will understand.
- Written Comprehension - The ability to read and understand information and ideas presented in writing.
- Deductive Reasoning - The ability to apply general rules to specific problems to produce answers that make sense.
- Inductive Reasoning - The ability to combine pieces of information to form general rules or conclusions (includes finding a relationship among seemingly unrelated events).
- Speech Clarity - The ability to speak clearly so others can understand you.
§ Bachelor’s Degree Required, Master’s Degree Preferred
We are an equal opportunity employer and we are committed to a work environment that promotes diversity, equity, and inclusion