Transitional Care Manager

Job summary

The transitional care manager is responsible for coordinating patient transitions of care by developing effective partnerships with patients, their caregivers/families, facility staff, community resources and physicians. Through these partnerships, the transitional care manager promotes high-quality care that is patient and family centered within and across healthcare and home settings.

Role and Responsibilities

· Collaborate with patients, their families/caregivers, healthcare professionals and community resources to develop a comprehensive plan of care that promotes health and meets the patient’s care goals.

· Address patient and family concerns about discharge.

· Conduct patient social risk factor assessment and anticipate potential gaps in care.

· Provide education to improve patient and family health literacy on patient’s condition and treatment plan.

· Facilitate patient access to appropriate medical and specialty providers as well as other care coordination team support.

· Provide timely communication and follow up with patients, families, and healthcare providers regarding changes in patient condition.

· Serve as a point of contact, advocate, and informational resources for patient, family, care team and community resources as needed.

· Assess the patient’s and family’s unmet health and social needs.

· Identify high-risk, complex patients that would benefit from transitional care services, chronic care management, and remote patient monitoring and assist patient and family in enrolling in programs.

· Help support patient and caregiver with transition from hospital to next level of care including facilitating follow-up appointments and communication of plan of care to next level of providers.

· Empower patients and caregivers to take an active and informed role in managing their care post-discharge.

· Work closely with hospital staff to assist with patient’s plan of care.

· Assist with transitional care clinic.

· Assist in data collection of key quality metrics and program performance improvement metrics.

· Attend and participate in in trainings and related meetings as required.

· Other duties as assigned.

Qualifications and Education Requirements

· Licensed registered nurse in the state of Illinois.

· At least two years professional experience care coordination or managing transitions of care.

· Knowledge and skills related to care coordination to successfully maintain excellent patient care.

· Strong communication, organization, and leadership skills.

· Ability to communicate proficiently through technology and maintain accurate notes and records.

· Ability to handle difficult situations involving patients, physicians, or others in a professional manner.

· Self-motivated and able to work both independently and in collaboration with others.

· Ability to maintain confidentiality of all medical, financial, and legal information.

· Ability to complete work assignments accurately and in a timely manner.

Job Type: Full-time

Pay: $38.00 - $40.00 per hour

Expected hours: 40 per week

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Weekends as needed

Education:

• Bachelor's (Required)

Experience:

• Nursing: 2 years (Required)
• Case management: 1 year (Required)

Work Location: In person

Salary : $38 - $40