Medical Home Transitional Care Coordinator
The Aroostook Medical Center 8 reviews - Presque Isle, ME

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Responsible for needs assessment and management of high risk or dual eligible patients admitted to acute and sub-acute care facilities and who may have no primary care provider, with the objective of ensuring appropriate discharge planning as well as allocation of medical resources to assure a smooth transition of care of care to an alternate setting.

Duties would include: Needs assessment of high risk and dual eligible patients, providing support and resources as needed. Paticipant in the discharge planning, education and advocacy, follow up calls to patients, SNF, Rehab to monitor progress. Position is a two year Grant Funded position.

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8 reviews