Care Manager (NURSE)

• Triage and assess patient’s medical-nursing, psycho-social, functional status and daily activity needs
• Assessment information to prioritize care needs and develop care plan and goals together with patient and ;caregiver
• Initiate conversation and discussion with patient or caregiver
• Suggest suitable referral to transitional care and community support services
• Work in partnership with patients and families/caregivers on the various ranges of services
• Monitor patient's general medical condition during home visit and report to patient's Principal physician
• Educate and promote advanced care planning, assist patients and their families/caregivers in planning
• Document assessments, plans, and outcomes promptly and accurately in the relevant system
• Maintain high level contact with step-down facilities

• Degree in Nursing with min 3 years of geriatric setting experience

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