| Location | Brunswick, Georgia |
| Website | http://careers.sghs.org |
Review daily hospital discharge reports and identify patients eligible for Transitional Care Management services and contact discharged patients within required regulatory timeframes to complete post-discharge outreach.
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Assess the patient's overall condition following discharge, including medication access and adherence, understanding of discharge instructions, new or worsening symptoms and questions or concerns regarding their care plan.
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Coordinate and schedule timely follow-up appointments with the primary care provider or appropriate specialists. Identify barriers to recovery, such as transportation, financial concerns, medication affordability, or home support needs, and coordinate appropriate resources. |
Document all patient interactions accurately and completely within the electronic medical record.
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Maintain compliance with CMS Transitional Care Management documentation and billing requirements.
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Collaborate with physicians, advanced practice providers, nursing staff, hospitals, home health agencies, skilled nursing facilities, pharmacies, and other healthcare partners to coordinate patient care.
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Participate in quality improvement initiatives focused on reducing readmissions and improving patient satisfaction.
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