**Company :**
Allegheny Health Network
**Job Description :**

**GENERAL OVERVIEW:**

This job collaborates with palliative care providers and other members of the interdisciplinary team to support effective outcomes and shared goals for patients and their families. Professional role model utilizing expertise in care management to promote a collaborative professional environment that supports excellence of care and achievement of optimal resource utilization.

**ESSENTIAL RESPONSIBILITIES**

+ Assumes role in assessment of patient physical, psychosocial, and economic needs for effective transition of care planning to a variety of levels of care.
+ Contributes to the development of the transition plan for the patient and the family.
+ Documents, verifies, and validates specific data required to monitor and evaluate interventions and outcomes.Interviews and collects patient specified data and chart review related to readmission.
+ Knowledgeab...