Registered Nurse - Complex & Transitional Care Manager Innovation Care Partners

Responsibilities

• Coordinate patient transitions between hospitals, skilled nursing facilities (SNFs), home health, primary care, and specialists.
• Conduct timely patient post-discharge follow-ups via telephonic calls or in-home visits, as warranted.
• Facilitate patient/caregiver education at transitions of care and chronic care management.
• Develop and implement individualized care plans and transition plans in collaboration with patient/caregiver, PCP and embedded Care Coordinators.
• Monitor progress toward goals, adjust care plans as needed, and advocate for access to appropriate services.
• Document assessments, care plans, and interventions in the electronic medical record (EMR) accurately and in a timely manner.
• Collaborate with the Chief Medical Officer, providers, primary care, embedded Care Coordinators and other health care professionals/agencies to ensure complex outpatient care is coordinated across the health care continuum.
• Participate in quality improvement initiative related to care transitions, chronic disease management, and utilization reduction.
• Maintain all regulatory educational requirements by participating in continuing education activities.
• Demonstrate professional behavior and promotes cooperation and team building.
• Maintain and manage to their caseload.
• Support and participate in the development and maintenance of scorecard.
• Maintain accurate metric tracking for daily productivity management.
• Perform other duties or responsibilities as assigned by people leader to meet business needs.

Requirements

• Education: Associates Nursing Required, Bachelors Nursing Required
• Experience: Licensed Registered Nurse - New grad Required, 1 year as Case (or Care) Manager, Transitional Care Manager, Care Coordinator RN or Nurse Advocate Required, 2 years Registered Nurse Preferred

Qualifications

• Licenses: Registered Nurse (RN) - License State And /Or Compact State Licensure Required
• Certifications: Basic Life Support (BLS) - Certification Required, Fingerprint Clearance Card (FPC) - Certificate Required, Certified Case Manager - Certification Preferred or Accredited Case Manager (ACM) - Certification Preferred