RN Transitional Care Manager

Purpose/belief statement:

The RN Transitional Care Manager is responsible for managing a patient’s successful transition from skilled nursing facility to hospital back to skilled nursing facility and/or additional acute care facilities such as Long-Term Acute Care (LTAC). Improving transitions between care settings is critical to improving a member’s quality of care, quality of life, and health outcomes. Additionally, improving care transitions may reduce unnecessary emergency department usage and prevent readmissions.

Job duties & responsibilities

• Coordinate hospital/institutional discharge planning and post discharge care.
• Facilitating communication and thoughtful handoff with assigned Care Manager and Interdisciplinary Care Team to continue TOC process once back to SNF
• Telephonically manage or provide support to other case management staff, including PHP, for members that travel outside the service areas.
• Acts as a SME for other case managers including nurse practitioners at PHP.
• Completion of hand off form with appropriate clinical supplementation; updated medication reconciliation and any case management recommendations made apparent during hospital stay.
• Identify issues that could lead to unnecessary complications related to care setting transitions and prevent unplanned and untimely transitions where possible.
• Collaborate with the hospital/institution discharge planner/coordinator to implement the discharge plan back to the member’s facility in which they reside.
• Work in collaboration with the Utilization Management Department to determine appropriateness of stay and/or need for utilization of “treat in place” and where admissions may be prevented.
• Maintain knowledge of Medicare benefits, Plan benefit plans, extra benefits, case management, and utilization management procedures, community resources, principles of self-determination, and patient-centered care.

Qualifications & Experience requirements

• Licensed Registered Nurse (RN) with both physical and behavioral health case management experience in an integrated setting preferred.
• Minimum of 3-5 years’ in Case Management preferred.
• Experience in Medicare Advantage programs preferred.
• Experience in Health Coaching, Diabetes Management or Cardiac Disease Management, or with older adults or people with disabilities a bonus.
• Ability and experience utilizing a variety of applications and databases to fulfill care management requirements, documentation.

Knowledge/Skills/Abilities

• Must have integrity and a strong ethical compass.
• Strong planning and organizational and time management skills with the ability to work independently.
• Must be excited by the opportunity to work within an integrated delivery system.
• Must have strong communication skills and the ability to work effectively with people coming from diverse cultural and professional perspectives.
• Knowledge of current models or standards of case management/transitional case management.
• Excellent interpersonal, written, and organizational skills required
• Must be a proactive and effective, creative problem-solver

Work environment

• May work beyond normal working hours, on weekends and holidays, when necessary.
• Occasional travel, less than 5%, possible facility visits.
• Must be willing to meet with families by phone or in person at times convenient tor families/providers.
• Must be willing to be a remote worker and have required internet service available to support laptop and applications.