Care Transition Care Manager, RN (Flexible Location)

Position eligible for – 

• Annual incentive bonus plan
• Medical, dental, and vision insurance with low deductible/low cost health plan
• Generous vacation and sick time accrual
• 12 paid holidays
• State Retirement (pension plan)
• 401(k) Plan with employer match
• Company paid life and disability insurance
• Wellness Programs
• Public Service Loan Forgiveness Qualifying Employer

See attachment for additional details. 

Office Location:  Mobile position; Available for any of Partners locations

Projected Hiring Range:  Depending on Experience

Closing Date:   Open Until Filled

Primary Purpose of Position:  

The purpose of this position is to ensures that members receive coordination and continuity of care as they transition between different settings or levels of care. This Includes but is not limited to; acute hospitals, EDs, skilled nursing homes, facility-based crisis, assisted living facilities and jail/prisons. This position will also assist members in their efforts to improve their quality of life across the Physical Health, Behavioral Health, Intellectual/developmental Disability (IDD), Traumatic Brain Injury (TBI), and Pharmacy domains to help prevent hospital readmission. The Care Transition Care Manager works with the member, Tailored Care Manager, and care team to identify and alleviate inappropriate levels of care or gaps in services. Travel is an essential function of this position. 

 Role and Responsibilities:  

The Care Transition Care Manager is responsible for (though not limited to):

• Support members transitioning from inpatient settings to the appropriate lower or lateral level of care
• Provide subject matter expertise, within scope, regarding member’s physical and/or behavioral health to support the development and delivery of a whole person approach to Care Management 
• Collaboratively works with other Partners team members, behavioral health providers, primary care physicians, specialty care providers and other community partners and stakeholders to support members in their home communities 
• Conducts on site visit with member during their stay in residential or inpatient settings (e.g., acute, ED and long–term stay facilities) 
• Conduct outreach to the member’s providers. 
• Obtain a copy of the discharge plan and review the discharge plan with the member, facility staff and Tailored Care Manager. 
• Facilitate clinical handoffs.
• Assist the member in obtaining needed medications prior to discharge, ensure an appropriate care team member conducts medication reconciliation/management and support medication adherence.
• Develop a ninety (90) day post-discharge transition plan prior to discharge from residential or inpatient settings, in consultation with the member, facility staff and the member’s care team, that outlines how the member will maintain or access needed services and supports, transition to the new care setting, and integrate into the community.
• Communicate and provide education to the member and the member’s caregivers and providers to promote understanding of the ninety (90) day post-discharge transition plan. (Assist with scheduling of transportation, in-home services, and follow-up outpatient visits with appropriate providers within a maximum of seven (7) Calendar Days post-discharge, unless required within a shorter timeframe.
• Ensures follows up with the member within forty-eight (48) hours of discharge.
• Appropriately escalate high risk/high visibility and/or complex barriers/needs members who may have difficulty transitioning out of the facility in a timely manner to supervisors. High risk can involve Health and Safety of a member, staff, or organizational risk 
• Review cases with clinical complexity with direct supervisor and follow escalation protocols to ensure timely engagement from members or our Medical Team and Provider Networks 
• Obtain information releases that will improve care management activities on behalf of the member

Knowledge, Skills and Abilities: 

• Extensive understanding of the Diagnostic and Statistical Manual of Mental Disorders (current version)
• Considerable knowledge of the MHSU/IDD service array provided through the network of the LME/MCO’s providers
• Knowledge of LME/MCO’s implementation of the 1915(b/c) waivers and accreditation
• Highly skilled at assuring that both long and short-range goals and needs of the individual are addressed and updated, while assuring through monitoring activities that service implementation occurs appropriately
• Exceptional interpersonal and communication skills
• Excellent computer skills including proficiency in Microsoft Office products (Word, Excel, Outlook, and PowerPoint) 
• Excellent problem solving, negotiation, arbitration, and conflict resolution skills
• Detail-oriented, able to organize multiple tasks and priorities and effectively manage projects from start to finish
• Ability to make prompt independent decisions based upon relevant facts, to establish rapport and maintain effective working relationships
• Ability to change the focus of his/her activities to meet changing priorities
• A high level of diplomacy and discretion is required to effectively negotiate and resolve issues with minimal assistance

 Education/Experience Required: 

**Licensed Care Manager: 

• Registered nurse (RN) plus one (1) year of experience. 
• Current Master’s level unrestricted fully licensed LCSW, LCMHC, LPA, LMFT, LCAS licensure with the appropriate professional board of licensure in the state of North Carolina, or bachelor’ s level working directly with individuals with serious mental illness (SMI).
• Employee is responsible for complying with respective licensure board’s continuing education/training requirements in order to maintain an active license. 

Other requirements:

• Must reside in North Carolina.
• Must have ability to travel as needed to perform the job duties

**In this role, when visiting hospitals, staff may be asked to verify the status of vaccination or immunization or a statement of exemption (including but not limited to COVID) to meet the requirements of the hospital.

Education/Experience Preferred: Licensed to practice as a Registered Nurse in North Carolina and two years of experience in nursing; care management/care coordination; care transitions experience.  Experience in collaborative care.

Licensure/Certification Requirements:  See requirements above