This position will be responsible for coordinating continuity of care in collaboration with the interdisciplinary team. Ensure clinical standards of care such as clinical practice guidelines, patients' care plans/care paths are addressed and met. Serve as liaison to ancillary and utilization review services, serve as communication link between health team members. Manage home referrals. Collaborate with Social Worker to ensure that barriers to discharge are managed, coordinate patient/family education, ensure that accompanying documentation, such as, advanced directives and agency choice are completed according to standards. Attend unit shift reports and staff meetings as indicated by unit manager. Participate and / or lead interdisciplinary rounds as needed.
**Buffalo, NY**