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RN Transitional Care Case Manager
RN Transitional Care Case Manager
Greensboro, NC • UM Care Management
The RN Transitional Care Case Manager is responsible for managing a member's successful transition from hospital to home and is accountable for developing, implementing, and evaluating comprehensive transitional care interventions for high, moderate, and low risk medical and/or surgical patients. The goal of the RN Transitional Care Case Manager is to manage the post-acute care of members to avoid and limit poor health outcomes, frequent emergency room visits, and hospital readmission.
The RN Transitional Care Case Manager risk stratifies hospitalized members for program enrollment and communicates with all entities involved in the care of the member to promote and maximize care coordination. Key aspects of the Transitional Care Program protocols are based upon inpatient and post-discharge workflows.
Upon patient hospital discharge, the post-discharge workflow is telephonic follow-up for up to 30 days facilitating clinical care, members' access to appropriate services, and service referrals and appointments. This according to the protocol, includes a focus on medication reconciliation and adherence, management of members' quality of life and functionality, management of acute disease states to bridge to disease/complex case management programs, identification and rectifying gaps in care, assessment, and support of patients ability to perform self-care, coordination of post-discharge appointments and services (durable medical equipment, home health) and coordination of care across the care continuum.
The Care Coordinator will be an advocate for appropriate resources available in the community, and across the continuum of care to best meet the needs of the member., This role will interact with all levels of personnel, medical staff, members, community resources, providers, and families.
Major Work Activities
Coordinates care provided to a community based high-risk population as follows:
Ability to effectively engage members by telephone to conduct thorough screening, physical and psychosocial assessments on the community-based caseload of members in a timely manner.
Consistently collaborates with members and family, physicians, and other healthcare team members to identify physical and psychosocial issues of barriers that affect health condition management.
Implements a comprehensive patient-centered plan of care to proactively manage these issues and effect positive health outcomes.
Prioritizes caseload to balance member and departmental needs.
Acts as a member advocate and coordination link with other healthcare providers and community resources to positively impact outcomes.
Advocates for the member to overcome barriers and resolve benefits issues. Assist members to navigate healthcare system and insurance benefits.
Thoroughly assesses each members' eligibility for needed resources.
Risk stratifies and identifies barriers or gaps in treatment and refers to the appropriate team member to address the need as indicated in holistic care positive outcomes.
Stays abreast of community resources and refers the Member for services and assistance when appropriate.
Willingly collaborates with healthcare team members to formulate an individualized care plan and goals that best meet the needs of the family/member.
Utilizes motivational interviewing techniques to engage members in goal setting.
Updates Care Enrollment to articulate current short-term and long-term goals as well as when these goals are met and or revised.
Consistently communicates with the healthcare team members to ensure patient care needs are addressed in a timely manner.
Communicates care coordination and key elements to providers per departmental requirements.
Monitors members adherence to treatment plan as follows:
Consistently monitors adherence to the member's treatment plan and relays issues to appropriate care providers promptly and effectively.
Proactively identifies barriers to adherence and acts promptly to revise the treatment plan to improve member adherence and outcomes.
Takes prompt action when issues involving the appropriate and cost-effective utilization of resources are identified, collaborating with appropriate healthcare team members.
Confers with the members, families, physicians and other care providers and insurance carriers in the role of patient advocate, as needed to resolve benefit issues and secure necessary service.
Provides documentation and telephonic disease management activities as follows:
Consistently documents all care management activities in the Care Enrollment Record(s) and or software applications using the established format in a timely and accurate manner per departmental requirements.
Promptly sends reports and communications to physicians and other providers as per the departmental requirements and as needed to relay pertinent findings.
Maintains accurate accounting of work hours to conduct UM business activities and submits in a timely manner.
Actively participates in program improvement activities.
Provides Health Education as follows:
Provides learner assessment to effectively provide individualized education to members and families.
Considers teaching methods based on individualized needs/differences.
Utilize a variety of approaches to effectively educate members and families as well as other members of the healthcare team regarding community resources, healthcare benefits, and insurance and managed care issues.
Follows up to evaluate the effectiveness of the education provided and documents.
Participates in multidisciplinary patient care conferences as needed.
Consistently and accurately documents health education activities in the documentation system per department requirements.
Appropriately updates departmental leadership with necessary formation.
Assists in program development and group education.
Mentors other telephonic staff members
Performs other duties as assigned.
Associated degree in nursing
Registered Nurse licensed in North Carolina or a Compact state
Current NC RN licensure in good
Annual flu shot
Five years nursing related care experience and/or home care experience combined
Required Knowledge, Skills, and Abilities
Knowledge of care management concept along the continuum
Knowledge of Medicare benefits
Experience and ability to use Microsoft Office products and word-processing software
Ability to successfully articulate the process of attaining goals and outcomes of care management
Ability to apply clinical knowledge and experience in a care management role
Ability to engage and collaborate with the member and significant others in the care management process
Ability to care manage diverse populations without applying one's own personal values
Ability to work with minimal supervision within nursing scope of practice
Ability to think critically and analytically and work with minimal supervision
Ability to evaluate and appropriately respond to verbal and non-verbal communication from patients in diverse stages of development
Ability to use good judgment to protect personal safety while performing duties
BSN or advanced degree in nursing
Case management certification
Case management, Care management, Telephonc Case management, and/or Disease management experience
Preferred Knowledge, Skills, and Abilities
Advanced clinical knowledge
Skills related to physician assessment, wound care, blood pressure monitoring, CBG checks, and Foley Cath care.
Clinical knowledge and ability to educate clients of all ages about the following core disease management issues: Diabetes, Hypertension, Hyperlipidemia, CAD, Asthma, COPD, and renal disease required. This is not intended to be an inclusive list of all conditions.
Time: Full time
Updated: 5/12/2021 9:39:12 AM