Readmission Prevention Case Manager RN - West Palm Beach /Remote

Meet with members, (and/or their caregivers) who are at high risk for readmission, post discharge, in person preferrably, within 2 business days of discharge. Perform an assessment of members current health status, including potential knowledge deficits, environment, care giver(s) and others supports, creating a care plan identifying problems, goals and interventions, based on member's responses, conditions, needs and priorities, as appropriate. Conduct Comprehensive Medication Reconciliation process, including education, identification of potential medication concerns, document and address any possible issues with the ordering physician, pharmacy, etc. and provide CMR report to PCP Validate the initiation of planned care and services, reinforce understanding of discharge instructions utilizing teach back methods, answer questions as appropriate and address concerns. Coordinate/assign necessary interventions including any available community resources, enhanced benefits or flex benefit to overcome potential barriers to care, e.g. meals, transportation, etc. Facilitate appropriate practitioner office follow-up visit within 7-14 days of discharge. Follow-up with member and practitioner to confirm appointment was kept. Provide continuing telephonic support/follow up for at least 30 days post facility discharge.