RN Inpatient Care Coordinator - Summit Medical Group

Provide transition of care services post inpatient hospitalization or emergency room visit, completing follow-up calls for a minimum of 30 days after discharge. Initiate communication with the multi-disciplinary healthcare team to develop and evaluate transition plans, while conducting medication reconciliation and submitting CPT code 1111F for Medicare Advantage patients within 30 days. Arrange post-discharge referrals to assist with chronic disease management, educate patients on appropriate care settings, and facilitate sharing of medical information across the continuum. Document all encounters in the electronic medical record and act as an advocate for individual health care needs. Collaborate with skilled nursing facilities and home health agencies to ensure ongoing care, while participating in required training, quality improvement activities, and staff orientation. Maintain strict confidentiality and adhere to corporate compliance plans.