SUMMARY :

Works with physicians and multidisciplinary team members to develop a plan of care for each assigned patient from admission through discharge.  Ensures patient is progressing toward desired outcomes by continuously monitoring patient care through assessment and/or evaluation.  Assesses and responds to patient/family/care giver needs by coordinating efforts of other treatment team members.  Identifies and resolves barriers that hinder effective patient care. Improves quality and completeness of documentation.

ESSENTIAL FUNCTIONS:

·         Collaborates and communicates with multidisciplinary teams in all phases of discharge planning process, including initial patient assessment, planning, implementation, interdisc...