Demo

Transition Care Management Coordinator

Metrolina Nephrology
Charlotte, NC Full Time
POSTED ON 2/6/2025
AVAILABLE BEFORE 5/4/2025

Metrolina Nephrology Associates is the region's most recognized and experienced nephrology group. The practice has been on the forefront of the treatment and management of kidney disease for more than 40 years. Our extensive network of 40 nephrology medical providers and 40 advanced practitioners and 8 convenient office locations allow our practice to deliver care in an atmosphere that is personal, patient centered, and compassionate.

It is our mission to provide the most comprehensive nephrology services available with a personal commitment to enhance our patients' quality of life through professional activity and dedication.

To attract the best and the brightest, Metrolina has competitive wages and benefits and a generous paid time off package beginning in your first year of employment : 4 weeks (accrued) paid time off PLUS 7 additional paid holidays! We offer two medical plans (high deductible and POS), employer paid employee dental, vision, employer paid basic life insurance, voluntary life insurance, short-term and long-term disability, critical illness, accident, legal and pet insurance. We also have a generous 401k plan with two entry dates after 90 days of employment. Voted by employees as a Best Places to Work in Healthcare by Modern Healthcare 3 years running.

Brings nephrology care oversight to a population of up to 6,000 nephrology patients with the potential of expansion. Works both directly and indirectly with as many as 17 nephrologists, 9 Advanced Practitioners and 19 clinical staff, ESRD Coordinator and ESRD Transition Coordinator in promoting an optimal patient experience beginning at time of intake.

Duties include, but not limited to :

  • Reviews hospital census daily for patient discharge identification
  • Communicates with patient within 48 hours of hospital discharge
  • Assess post-discharge needs through discharge summary and additional hospital notes
  • Recognizes TCM patient complexity
  • Secures a Face-to-Face encounter within 7-14 business days of hospital discharge, dependent on recognition of complications
  • Completes medication reconciliation
  • Intuitive to patient disease progress
  • Communicates with ESRD Coordinator regarding Vascular appointments initiated during hospital stay
  • Collaborates with Home Therapies Coordinator for scheduling treatment options
  • Supports patients and their families as they move through each level of care

Requirements

Education : High School Diploma or general equivalency diploma (GED). Completion of a medical assistant training program through an accredited school or graduate of an accredited nursing program.

Experience : Minimum of three years' experience working in a medical facility as a medical assistant / nurse.

Certification : CMA / RMA - Medical assistant certification has been maintained. Nurse - must hold a current and valid North Carolina license. Current CPR certificate.

Attendance : Regular, reliable, and punctual attendance is an essential function of this position. The ability to consistently adhere to scheduled work hours and fulfill job responsibilities in a timely manner is critical to the success of the role and the overall operations of the team.

Communication Skills : Excellent communication skills, able to communicate effectively at all levels of the organization; able to effectively resolve conflict situations, able to work collaboratively with physicians, directors, managers and staff. Able to promote free-flowing 2-way communication with patients and their support systems.

Required soft skills :

  • has a professional presence
  • excels at working independently
  • is proficient at multi-tasking
  • can quickly build a rapport with patients
  • anticipate various disease progression questions
  • able to engage patients in their on-going health care
  • extremely organized
  • has a sound knowledge of disease progression affording them the ability to be intuitive to "next steps" / questions
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