Transitional Case Manager

Provides psychosocial assessments, crisis intervention, resources referrals, to facilitate discharge plans, and/or adjustment to illness, and complex discharge planning for patients and their families.   Formulates the discharge plan with patient, families and the care team based upon a needs assessment.   Coordinates appropriate referrals to home care agencies, skilled nursing and rehabilitation centers, and community-based programs.   Coordinates care authorization process with insurers   Coordinates specific details of patient’s hospitalization with Utilization Management department to ensure appropriate admission status .