RN - Transitional Care Coordinator-Jeff Hwy

Job Overview

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 service 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.

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.

• Collaborates 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.
• Assesses patient for social determinants of health that may create barriers to care and/or adversely impact the care and treatment plans. Includes SDOH in the care/treatment plan and refers to Social Work or Community Health Worker as appropriate and guided by workflow/process.
• Uses the case management process to develop comprehensive cost‑effective plans of care for patients in care management.
• Collaborates with the multidisciplinary team, Primary Care Provider, and other appropriate care providers to facilitate appropriate care and treatment of the patient.
• Coordinates referrals and appointments with members of the care team.
• Provides in‑depth disease‑based patient education and formulates collaborative action plans with patient/caregiver to achieve agreed‑upon goals for self‑management and to improve patient health status.
• Provides community resources to patient, families and/or caregivers to avoid or reduce hospital admission through telephonic and face‑to‑face contact.
• Identifies quality issues that may adversely affect patient outcomes and submits to department leadership.
• Performs other related duties as required.

Light Work – Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects. ... Normal routine involves no exposure to blood, body fluid or tissue, but exposure or potential for exposure may occur. ... Because the incumbent works within a healthcare setting, there may be occupational risk for exposure to hazardous medications or hazardous waste within the environment ...

The employer is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, or disability status.