Transitional Care Manager

Position Title : Transitional Care Manager

If you want to know about the requirements for this role, read on for all the relevant information.

Location : Remote (Corporate)

Schedule : Full-Time

Job Type : Permanent

Job Description

We are seeking an experienced and compassionate Transitional Care Manager to support patients during critical points of care transition. This role is responsible for ensuring seamless coordination of care, promoting patient quality outcomes, and supporting cost-effective healthcare delivery. By leveraging clinical expertise and patient-centered communication, the Transitional Care Manager will collaborate with clinical teams, providers, patients, and insurance companies to facilitate smooth transitions between care settings and reduce the likelihood of hospital readmissions.

If you are a dedicated healthcare professional with a passion for patient advocacy, care coordination, and improving healthcare outcomes, this role is an exciting opportunity to make a significant impact.

Key Responsibilities

Care Coordination & Planning : Conduct needs assessments and develop individualized, comprehensive treatment plans to support patients during transitions of care.

Collaboration & Communication : Work closely with providers, Utilization Management (UM) staff, insurance companies, and social support services to coordinate patient care and ensure a smooth transition.

Patient Support & Education : Educate patients on their care plans, prescribed treatments, and available support resources such as social work, insurance benefits, and community assistance programs.

Regulatory Compliance : Ensure alignment with regulatory standards and internal procedures for care and quality management processes.

Data Documentation : Record treatment plans, care coordination tasks, and actions in the Electronic Medical Record (EMR) system with strict attention to detail and within specified timeframes.

Chronic Condition Management : Support chronic and high-risk patients by providing ongoing monitoring, guidance, and education, including information on Advanced Directives.

Readmission Prevention : Work with Utilization Management (UM) staff to reduce hospital readmissions and focus on meeting CMS STAR measures related to transitions of care and medication reconciliation.

Ongoing Patient Evaluation : Provide ongoing support to patients, continuously monitoring and evaluating care plans to ensure optimal outcomes.

Knowledge, Skills, and Abilities

Clinical Knowledge : Deep understanding of chronic condition management, high-risk patient care, and healthcare best practices.

Managed Care Expertise : Knowledge of managed care concepts, Medicare Advantage, and related case management programs and services.

Patient Advocacy : Ability to support and educate patients, family members, and caregivers, ensuring they are empowered in their healthcare journey.

Data & Documentation : Proficiency with Electronic Medical Record (EMR) systems, data entry, and accurate documentation of care plans and patient information.

Critical Thinking & Problem-Solving : Ability to analyze data, identify issues, and develop effective solutions to complex problems.

Interpersonal & Communication Skills : Excellent written and verbal communication skills to interact with diverse stakeholders, including patients, providers, and payers.

Time Management : Ability to manage multiple priorities, meet deadlines, and respond promptly to changing care needs.

Minimum Qualifications

Licensure : Current Nursing License (RN preferred) within the state of practice or a Compact License. LPNs with managed care experience may also be considered.

Experience : Minimum of 2 years of clinical practice experience, with at least 1 year in care (case) management.

Education : Must have continuing education in care (case) management and other relevant licensure requirements.

Certifications : CPR / BLS certification required.

Preferred Qualifications

Specialized Certifications : Certification as a Diabetes Educator, Nutritionist, Social Worker, or a related healthcare specialty is preferred but not required.

Physical & Mental Requirements

Physical Demands : Ability to sit, stand, and walk for extended periods of time.

Strength Requirements : Ability to lift up to 50 pounds and push / pull heavy objects using up to 100 pounds of force.

Fine Motor Skills : Use of fine motor skills to operate equipment or machinery as needed.

Cognitive Abilities : Ability to comprehend and apply verbal and written instructions.

Logical Reasoning : Use of logical reasoning to solve both simple and complex problems.

Driving & Travel : Must be able to drive and operate a vehicle for occasional travel to support clinic activities, attend meetings, and participate in training.

Work Environment : This position is based in an office environment but may require interaction in healthcare facilities with possible exposure to communicable diseases or bodily fluids.

ttg Talent Solutions is an Equal Opportunity Employer and recruiting agency. We are committed to creating an inclusive and diverse work environment and welcome applications from all qualified candidates regardless of race, color, religion, gender, sexual orientation, national origin, age, disability, or veteran status. Please note that all offers of employment are contingent upon the successful completion of a drug test and background check. We maintain a drug- and substance-free workplace to ensure the safety and well-being of all employees.

At ttg, 'We believe in making a difference One Person at a Time,' ttg OPT.

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