PRN Case Manager - Transition Support Post Discharge

Job Responsibilities

• Attends interdisciplinary team meetings and identifies patients who qualify for the Transition Support Program.
• Collaborates with interdisciplinary team and obtains report from referring CM and primary RN.
• Mets with the client/family prior to discharge to explain the role and function of Transition Support services.
• Works closely with client’s physicians to address needs/concerns (medical needs, therapy goals, vocational interests/goals, and patient financial status, etc.) as they arise.
• TSP CM calls every client/family at a minimum of once a week and is available throughout the week to answer unlimited calls and emails from client/family.
• Develops a mutually acceptable plan of care to maximize health and safety goals.
• Helps facilitate community re-entry and assists clients/caregivers in locating community-based resources.
• Aids in the identification of financial grants/waivers and assists with the completion of applications.
• Continues the coordination of physician orders to outside suppliers.
• Aids in the identification of patient and family education needs and provides necessary re-education.
• Provides ongoing education, guidance, and support post discharge, with a strong focus on medical, financial, and psychosocial needs.
• Completes thorough and accurate documentation in electronic records.
• Practices proper safety techniques in accordance with Center and departmental policies and procedures.
• Reports employee/patient/visitor injuries or accidents, or other safety issues to the supervisor and in the occurrence notification system.
• Maintains compliance with all regulatory requirements, organizational standards, and policies and procedures related to area of responsibility.
• Identifies potential risk areas within area of responsibility and supports problem resolution process.

Required Minimum Education

Bachelor’s degree in Nursing

Required Minimum Certifications

CCM required within 2 years.

Required Licensure

Active Georgia RN license or NLC/eNLC Multistate License.

Required Minimum Experience

A minimum of at least 5 years of experience as an RN required. Experience working with patients who have sustained brain and/or spinal cord injuries is preferred.

Required Minimum Skills

• Excellent judgment, time management and communication skills required.
• Self-motivated, dependable, and able to meet deadlines.
• Demonstrates critical thinking, cultural diversity, and advocacy.
• Able to appropriately handle sensitive and confidential information.