RN Transitional Care Manager

CommuniCare Corporate • Full-time • Blue Ash, OH, US • 1d ago

Purpose/belief statement:

The RN Transitional Care Manager is responsible for managing a patient’s successful transition from skilled nursing facility to hospital back to skilled nursing facility and/or additional acute care facilities such as Long-Term Acute Care (LTAC). Improving transitions between care settings is critical to improving a member’s quality of care, quality of life, and health outcomes. Additionally, improving care transitions may reduce unnecessary emergency department usage and prevent readmissions.

Job duties & responsibilities

Coordinate hospital/institutional discharge planning and post discharge care.
Facilitating communication and thoughtful handoff with assigned Care Manager and Interdisciplinary Care Team to continue TOC process once back to SNF
Telephonically manage or provide support to other case management staff, including PHP, for members that travel outside the service areas.
Acts as a SME for other case managers including nurse practitioners at PHP.
Completion of hand off form with appropriate clinical supplementation; updated medication reconciliation and any case management recommendations made apparent during hospital stay.
Identify issues that could lead to unnecessary complications related to care setting transitions and prevent unplanned and untimely transitions where possible.
Collaborate with the hospital/institution discharge planner/coordinator to implement the discharge plan back to the member’s facility in which they reside.
Work in collaboration with the Utilization Management Department to determine appropriateness of stay and/or need for utilization of “treat in place” and where admissions may be prevented.
Maintain knowledge of Medicare benefits, Plan benefit plans, extra benefits, case management, and utilization management procedures, community resources, principles of self-determination, and patient-centered care.

Qualifications & Experience requirements

Licensed Registered Nurse (RN) with both physical and behavioral health case management experience in an integrated setting preferred.
Minimum of 3-5 years’ in Case Management preferred.
Experience in Medicare Advantage programs preferred.
Experience in Health Coaching, Diabetes Management or Cardiac Disease Management, or with older adults or people with disabilities a bonus.
Ability and experience utilizing a variety of applications and databases to fulfill care management requirements, documentation.

Knowledge/Skills/Abilities

Must have integrity and a strong ethical compass.
Strong planning and organizational and time management skills with the ability to work independently.
Must be excited by the opportunity to work within an integrated delivery system.
Must have strong communication skills and the ability to work effectively with people coming from diverse cultural and professional perspectives.
Knowledge of current models or standards of case management/transitional case management.
Excellent interpersonal, written, and organizational skills required
Must be a proactive and effective, creative problem-solver

Work environment

May work beyond normal working hours, on weekends and holidays, when necessary.
Occasional travel, less than 5%, possible facility visits.
Must be willing to meet with families by phone or in person at times convenient tor families/providers.
Must be willing to be a remote worker and have required internet service available to support laptop and applications.

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