RN - Transitional Care Coordinator-Jeff Hwy

This job manages identified complex/catastrophic patients attributed to the organization and its Network of partner providers. Uses the case management process to assess the healthcare needs of the enrollee, identify barriers to care, develop a comprehensive treatment plan complete with specific goals and objectives, implement a treatment plan in collaboration with the PCP team and the other providers involved in the patients’ care, negotiate and coordinate services for the patient, monitor and evaluate the effectiveness of the plan in achieving the goals and objectives, and change and modify the plan as needs and situations change.

This job is an integral part of the multi‑disciplinary care team and as such coordinates care among multiple healthcare providers, the patient’s caregiver(s), community services, payors, and others involved in the care of the patient to ensure services are provided seamlessly throughout the continuum of care. Arranges and coordinates resources necessary to manage the patient’s disease processes in the home environment.

This job adheres to the CMSA Standards of Practice for Care Management. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential duties.

Required:

Graduate of an accredited school of nursing.

Preferred:
Bachelor’s degree in nursing.

Required:

3 years of experience in a clinical setting; experience documenting in an electronic medical record and using Microsoft Office; experience working in a multi‑disciplinary team environment.

Preferred:
Experience in case management, care coordination or disease management.

Required:

Current Registered Nurse (RN) license in the state of practice.

Preferred:
Certification as a Case Manager (CCM).

• Proficiency in using computers, software, and web‑based applications.
• Effective verbal and written communication skills and ability to present information clearly and professionally to varying levels of individuals.
• Excellent knowledge of managed care, CMS, Medicaid and other regulatory standards/requirements and ability to use community resources and other resources to facilitate the patient’s care throughout the care continuum.
• Good organizational and time‑management skills and ability to be self‑directed and demonstrate good judgement.

• Collaborate with members of the health care team, the patient, and patient’s caregiver(s) to develop and implement a coordinated treatment plan across the continuum.
• Assess patient for social determinants of health that may create barriers to care and/or adversely impact the care and treatment plans. Include SDOH in the care/treatment plan and refer to Social Work or Community Health Worker as appropriate and guided by workflow/process.
• Use the case management process to develop comprehensive cost‑effective plans of care for patients in care management.
• Collaborate with the multidisciplinary team, Primary Care Provider, and other appropriate care providers to facilitate appropriate care and treatment of the patient.
• Coordinate referrals and appointments with members of the care team.
• Provide in‑depth disease‑based patient education and formulate collaborative action plans with patient/caregiver to achieve agreed‑upon goals for self‑management and to improve patient health status.
• Provide community resources to patient, families and/or caregivers to avoid or reduce hospital admission through telephonic and face‑to‑face contact.
• Identify quality issues that may adversely affect patient outcomes and submit to department leadership.
• Perform other related duties as required.

The above statements describe the general nature and level of work only. They are not an exhaustive list of all required responsibilities, duties, and skills. Other duties may be added, or this description amended at any time. Remains knowledgeable on current federal, state and local laws,…