Transitional Care Management Jobs in Minnesota (NOW HIRING)

At M Health Fairview University of Minnesota Medical Center - West Bank Campus in Minneapolis, MN we are committed to providing exceptional healthcare in a setting where we specialize in innovation. We continually strive to improve our patients' lives by delivering superior outcomes using groundbreaking technology and treatments while balancing patients' needs.

Our partnership with the University of Minnesota Medical School and University of Minnesota Physicians provides the platform to specialize in breakthrough treatments, surgical techniques, lifesaving therapies and to train tomorrow's physicians. Clinical trials advance our clinical services, bringing the very newest ideas in patient care. 

The Patient Care Management Coordinator, is a Nursing RN position and will be working on the Acute Rehab Center and the Transitional Care Unit.

• ARC (Acute Rehab Center)
• 30 beds of inpatient rehab.
• Serves multiple diagnoses including neuro, ortho, oncology, amputee, spinal cord injury, transplant, etc.
• Primarily adults, however see adolescents ages 13+.

• Transitional Care Unit
• 28 beds 
• Serves multiple diagnoses including neuro, ortho, oncology, amputee, spinal cord injury, transplant, etc. 
• All adults
• Post-Acute – PT, OT, SLP.
• Approximately 50 therapy and tech staff at the 2 post-acute units 
• Highly Collaborative between all disciplines along with MD/Physiatrist, rehab nursing, social work, dietary, etc. with primary goal to get patient’s home.

This position will be 56 hours hours in a 2 week pay period on the day shift, 8-hour shifts, no weekends. 

About this Position:

This Patient Care Management Coordinator provides comprehensive care coordination of patients as assigned. The care coordinator assesses the patient’s plan of care and develops, implements, monitors and documents the utilization of resources and progress of the patient through their care, facilitating options and services to meet the patient’s health care needs. The intensity of care coordination provided is situational and appropriate based on patient need and payer requirements. This position is accountable for the quality of clinical services delivered by both them and others and identifies/resolves barriers which may hinder effective patient care.

This position has responsibility to determine how to best accomplish functions within established procedures, consulting with leader on any unusual situations. Internal customers include all levels of nursing management and staff, medical staff, and all other members of the interdisciplinary health care team. External customers include physicians and their office staff, payers, community agencies, provider networks, and regulatory agencies.

Manages patients across the health care continuum to achieve the optimal clinical, financial, operational, and satisfaction outcomes.

• Acts as one point of contact for patients, physicians and care providers throughout the patient’s hospitalization.
• Initiates/implements transition functions and activities for patients communicating with patients, families and the health care team to ensure seamless transitions.
• Assesses patient admissions and continued stay utilizing evidence based criteria.

Contributes to the development and implementation of individualized patient care plans.

• Collaborates with health care team partners and patients/family to manage the patient discharge plan.
• Effectively communicates the plan across the continuum of care.

Assist in the development and implementation of process improvement activities to achieve optimal clinical, financial and satisfaction outcomes.

• Enables efficiency in care by identifying and reducing delays, ensuring appropriate level of care, facilitating length of stay reductions and identifying resources to promote a safe and effective discharge.
• Collects data and other information required by payers to fulfill utilization and regulatory requirements.

Identify and communicate, to appropriate leader, all issues related to case escalation.

Establishes a collaborative relationship with physicians, medical directors, nurses and other unit staff, and payers.

• Demonstrates effective communication by being a critical link with attending and consulting physicians and all health care team members and payers. Facilitates resolution to any identified issues.
• Mentors internal members of the health care team on case management and managed care concepts.

Understands and focuses on key performance indicators.

• Actively tracks outcomes and participates in quality planning.
• Facilitates integration of concepts into daily practice.

Required Qualifications

• Education/Experience: Bachelor’s Degree in Nursing with 3 years Clinical experience or AD degree with 5 years of clinical experience

• License/Certification/Registration: Active MN Registered Nurse license

Preferred Qualifications

• 1+ years of working as a care coordinator/case manager

Fairview offers a generous benefit package including but not limited to medical, dental, vision plans, life insurance, short-term and long-term disability insurance, PTO and Sick and Safe Time, tuition reimbursement, retirement, early access to earned wages, and more! Please follow this link foradditional information: https://www.fairview.org/careers/benefits/noncontract

An individual's pay rate within the posted range may be determined by various factors, including skills, knowledge, relevant education, experience, and market conditions. Additionally, our organization prioritizes pay equity and considers internal team equity when making any offer. Hiring at the maximum of the range is not typical. If your role is eligible for a sign-on bonus, the bonus program that is approved and in place at the time of offer, is what will be honored.

$48.11- $69.49 Hourly