Transitional Care Manager
The Transitional Care Manager position, which utilizes a broad range of skills, clinical expertise and proficiency in complex case management, utilization review, care coordination and discharge planning will facilitate care management during admission and set-up transition plans post discharge. The Transitional Care Manager will make visits at inpatient facilities, visit the members, perform assessments, evaluate members progress, review utilization of services, communicate to the AbsoluteCARE Team, collaborate with the inpatient team, provide care plan interventions, coordinate care and ensure quality service. The Transitional Care Manager will have strong communication and leaderships skills as well as the ability to work autonomously in the field while being accountable to the AbsoluteCARE team at the practice site. The Transitional Care Manager will have enthusiasm about coaching, educating and supporting members during inpatient stay and will be highly motivated to help our company fulfill its larger mission of providing patient centered ambulatory ICU service and complex case management for our vulnerable and at-risk members. The Transitional Care Manager will be people-centered, supportive and flexible to get the most of his/her members; focused on navigating member through the care continuum to improve quality of life, health outcomes while decreasing unnecessary emergency room visits and avoidable admissions.
Duties and Responsibilities
- Provide face-to-face and telephonic case management services to vulnerable and at-risk members;
- Visit inpatient members and high utilizers of emergency room and/or observation stays to coordinate care, identify alternative or different level of care service options;
- Perform utilization reviews evaluating treatment plan and quality of care, offering care alternatives, interventions and services specific to the needs of the members facing barriers and social determinants of health that are complicating member’s episode;
- Consult with the center medical director for difficult cases needing leadership and collegial level discussions with facility physicians, medical directors, family meetings and care givers.
- Facilitate communication between the primary care provider and the hospitalist/consultants and/or SNF-ist for collaboration and consultation regarding member’s care, treatment and discharge planning.
- Perform comprehensive assessments to evaluate member’s medical, social and behavioral needs while identifying member/family strengths, health behaviors, social determinants of health, barriers, and resources;
- Develop a strong collaborative relationship with the AbsoluteCARE home based care manager to actively manage the member during the 30 – 45 post discharge period, the AbsoluteCARE care manager to extend care plan interventions in the home and ensure timely follow-up at 48 hours, and 7 – 14 days post discharge and the treatment and triage nurse to identify appropriate onsite care alternatives for those frequently visiting the emergency room;
- Collaborate with inpatient facility team comprised of hospitalists, case managers, discharge planners, social workers, charge and staff nurses and AbsoluteCARE’s multi-disciplinary team to facilitate post discharge planning and transition to the home;
- Coordinate with AbsoluteCARE multi-disciplinary team, patient, family, and caregivers to help resolve barriers to care and transition member back to AbsoluteCARE’s Ambulatory Care ICU - Patient Centered Medical Home Center;
- Intervene prior to or at time of condition exacerbation or decline in medical and/or behavioral health to help members appropriately utilize healthcare services – the right place, at the right time for the right condition and intensity of service needed to avoid unnecessary emergency room visits and avoidable hospitalizations;
- Establish & maintain strong collaborative working relationships with inpatient facilities and community care organizations like hospitals, skilled nursing facilities and hold meetings with these entities regarding public & community health topics;
- Advocate on member/family’s behalf and support engagement through warm handoffs and timely, relevant and proactive communication;
- Licensed Registered Nurse with 3 + years related complex case management and 3 + years of diverse clinical background in >2 care settings (hospital, SNF, home health, rehab);
- Must be willing to travel up to 75% of the time to local area hospitals, SNFs or community organizations to visit members and build relationships with staff;
- Bachelors with Case Management or Care Coordination certification (CCM or CCTM) preferred;
- Excellent communication and leadership skills;
- Self-starter with great organizational skills and attention to detail;
We aim for the highest quality and most cost effective medical and wellness care in a private setting that offers comprehensive medical, laboratory, pharmacy, radiology, nutrition, educational and support services. AbsoluteCARE provides Compassionate, Confidential, Comprehensive and Culturally-Effective Care for Patients and their Families.
Why Work Here?AbsoluteCARE provides comprehensive primary health care to adolescents (16 years and older) and adult patients. Our comprehensive approach is specifically geared towards care for health, wellness and prevention. Our practice specializes in the management of chronic conditions such as diabetes, hypertension, COPD, heart disease, congestive heart failure and asthma. We aim for the highest quality and most cost effective medical and wellness care in a private setting that offers comprehensive medical, laboratory, pharmacy, radiology, nutrition, educational and support services. AbsoluteCARE provides Compassionate, Confidential, Comprehensive and Culturally-Effective Care for Patients and their Families.
Comprehensive benefits, the supportive family-like company culture, state-of-the-art facilities and of course career growth!