Transition Care Manager RN
Job Description
POSITION SUMMARY:
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This position would focus on care coordinates and implements the function of transition planning for inpatient and outpatient services. Identifies and anticipates transitional care planning needs for each identified patient. Communicates and collaborates with the patient and post-acute primary providers through verbal and written communication. Responsible for the integration of the patient into the care of post-acute primary care using standards of transitional planning (developing, planning, implementing, and evaluating) in accordance with existing federal, state, and local standards. Adheres to confidentiality policies specific to communication, record keeping, and coordination of services. Responsible for documentation in all areas of transitional care. Transition Care Manager will provide assistance to patients, families, and/or significant others. Facilitates assistance when psychosocial factors impact the recovery process. The Transition Care Manager is responsible for applying medical necessity criteria to patients entering the hospital. Education is provided to physicians and other members of the team on the issues related to utilization review including inappropriate admissions and placements. Acts as patient advocate by negotiating for, and coordinating resources with payers, agencies and vendors for treat and release patients, as appropriate. This position is responsible for implementing specific readmission prevention activities in collaboration with the physician and hospital staff, such as collecting patient clinical and demographic data, educating the patient and family on disease management strategies, arranging for post- discharge support services. Transitional Care Manager seeks guidance from VP oof Care Management as needed |
KEY RESPONSIBILITIES:
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REQUIRED KNOWLEDGE & SKILLS:
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Experience in one or more areas (multiple experience preferred) of transitional care planning, discharge planning, social services, and/or care management. Demonstrates ability to interpret a variety of handwritten clinical data. Maintains attention to detail in a fast-paced work environment with minimal supervision. Maintains a pleasant, tactful manner when working with people in stressful situations. Is familiar with Medicare/Medicaid regulations and financial assistance. Is skillful in dealing with physicians to resolve transitional care issues. Possesses a working knowledge of community resources and services. Acts as a liaison between physicians, staff, patients, and families. The Transitional Care Manager assesses patients to identify psychosocial needs requiring intervention. It is recognized that there are variations in the approach utilized by different practitioners. |
EDUCATION/EXPERIENCE/LICENSURE/TECHNICAL/OTHER: |
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Application Instructions
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