Care Manager RN - Transitions of Care

Description

Join the Erie team! Motivated by the belief that healthcare is a human right, we provide high quality affordable care to support healthier people, families, and communities. Erie delivers holistic care to help every member of the family stay healthy and active from infancy through adulthood. Since 1957, we have provided high-quality care to diverse patients most in need, regardless of their insurance status, immigration status, or ability to pay.

Erie Family Health Centers, a nationally recognized top workplace with 13 sites in Chicago and suburbs, is looking for a valuable addition to our Care Management Team! The Care Manager RN - Transitions of Care (TOC) partners with other care managers and an interdisciplinary care team to ensure patients transition between care settings with the best possible outcomes.   By providing comprehensive, high-quality, patient-centered transition, patients will have an understanding of discharge instructions, and the Erie care team will be well prepared to support next steps. The Care Manager RN TOC ensures that high-risk and recently hospitalized patients receive the appropriate time-sensitive outreach and/or clinical support which includes care coordination activities to transition between care settings and the community.

At Erie, we are proud to provide competitive salaries, high-quality health care plans, generous time off benefits, retirement benefits, and more! Erie employees are eligible for Erie’s Full Benefits Package that includes Medical, Dental, Vision, Life and Disability Insurance and Flexible Spending (FSA) for Health Care or Childcare. Retirement Programs: 401(k) program with Erie matching $0.50 for every $1.00 up to the first 5% of the employee’s biweekly salary. Annual Paid Time Off: starting at 20 days of PTO, and 8 paid holidays. Competitive salary, annual merit increases, plus room for growth and career advancement.

Main Duties & Responsibilities

Transitions of Care / Care Management

• Conducts transition of care outreach to hospitals and patients.
• Completes appropriate assessments, care plans, and documentation for patients transitioning between the hospital, Skilled Nursing Facilities, home, and other care settings.
• In partnership with patient’s care team, identifies clinical concerns and acuity, risk factors, and barriers to adherence to discharge plan and managing health condition(s).
• Provides care coordination/care management services to facilitate transition of care between hospital, consulting physicians, community resources, and Erie, including handling cases that require follow-up per external partner request.
• Collaborates and provides clinical support to community health workers (CHWs), care management, and other patient programs team members, including referral to eligible supportive services. Some of this work may be required to be completed in person.
• Works with patients in short- and long-term capacities managing and coordinating care.

Qualifications

Skills and Knowledge

Required:

• Strong computer skills required: expert in Microsoft Office, Excel and ability to learn to expert level other electronic databases (Epic electronic medical record system, etc.). 
• Active CPR card required. 
• Comfort using phone-based translation services required.

Preferred:

Bilingual fluency (English/Spanish) preferred. (May be required to assist or work with non-English/Spanish only speaking patients and/or guests.)

The Erie Advantage Pledge

WORKING TOGETHER FOR WHAT MATTERS MOST

Erie makes a pledge that all current and future employees can feel confident that:

• Our mission, vision, and values unite us.
• Our voices matter.
• We do things well.
• Our inclusive culture promotes balance and belonging.
• We find our career sweet spot at Erie.

Salary : $73,000