Care Manager - Care Transitions (RN)

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About the Role

The Transitional Care Case Manager (TCCM) is a clinical liaison between health care providers to ensure the continuation of care for healthcare consumers. These consumers are inpatients transitioning from the hospital to the next level of care and have been identified as high risk for readmissions. The TCCM follows the healthcare consumer for up to 30 days (90 days for TKA/THA) after each inpatient episode to assist in self-care management and interventions as needed. Using an evidence-based care coordination approach, the TCCM provides services designed to streamline the consumer's plan of care and interrupt patterns of frequent acute hospitalization or emergency department use. Transitional Care Case Management serves as a means for achieving client wellness and autonomy through advocacy, communication, education, identification of service resources, and service facilitation.

Responsibilities

• Identifies high-risk admissions and prioritizes patients.
• Uses comprehensive assessment, planning, implementation, evaluation skills, and outcome targeting related to the diagnosis.
• Assists the healthcare consumer and support system(s) in identifying and securing appropriate services to address needs across the healthcare continuum.
• Performs follow-up telephone calls with the healthcare consumer/support system.
• Provides education to the healthcare consumer/support system on the disease process when needed.
• Reviews the home medication list and determines the level of understanding of the medication regimen.
• Reviews the discharge plan with the healthcare consumer/support system.
• Encourages scheduling a follow-up visit with the primary care physician and assesses if the healthcare consumer has transportation to the appointment.
• Performs interventions after discharge, as needed.
• If discharged home and meets criteria, offers a transitional home visit for healthcare consumers.
• Documents activities, events, and information per standards in established software systems in a timely, accurate, and complete manner.
• Maintains ongoing reports of all open and closed cases.
• Collaborates with the healthcare consumer, support system(s), and others in the conduct of nursing practices.
• Employs strategies to promote health and a safe environment.
• Assists the healthcare consumer in self-determination by utilizing informed decision-making.
• Treats the healthcare consumer and support system(s) with respect.
• Uses established policies and processes to handle, discuss, and transmit protected health information in a manner consistent with privacy and compliance expectations and policies.
• Monitors high-risk complex care patients and collaborates to problem-solve issues with complex patients and identify trends.
• Formulates potential solutions with the interdisciplinary care team and continuously monitors cases/follows up on all action items.

Requirements

• Must be licensed to practice as a Registered Nurse in the state of North Carolina or one of the compact states.
• Basic Life Support (BLS) certification.

Qualifications

• Bachelor's of Science in Nursing (BSN) preferred.
• Experience working in a Case Management/Discharge Planning capacity preferred.
• Hired applicants will be expected to obtain Care Management certification.

Job Details

This is a full-time, onsite position located at Pardee Hospital. Standard hours per week: 40.00. Work schedule: Day. Exempt from overtime: Yes.