Transition of Care Coach (RN) Remote (Must Reside in Michigan)

About the role

This RN will act as a Transition of Care Coach supporting our Michigan Medicare and Dual members who have recently been admitted to this hospital. The TOC Coach will support them to ensure a successful transition from inpatient to discharge to either a nursing facility or back to their home. The position is a combination of phone call outreach and virtual meetings with the members while still inpatient.

Responsibilities

• Follows member throughout a 30 day program that starts at hospital admission and continues oversight through transitions from acute setting to all other settings, including nursing facility placement/private home, with the goal of reduced readmissions.
• Ensures safe and appropriate transitions by collaborating with the hospital discharge planner, as well as collaborating with hospitalists, outpatient providers, facility staff, and family/support network.
• Ensures member transitions to setting with adequate caregiving and functional support, as well as medical and medication oversight support.
• Works with participating ancillary providers, public agencies or other service providers to make sure necessary services and equipment are in place for safe transition.
• Conducts telephonic virtual visits of all members while in the hospital and, high-risk members post-discharge as needed.
• Carefully assesses for barriers to care, provides care coordination and assistance to member to address concerns.
• Facilitates interdisciplinary care team meetings (ICT) and collaboration.
• Provides consultation, recommendations and education as appropriate to non-behavioral health care managers.

Requirements

• At least 2 years experience in health care, with at least 1 year of experience in hospital discharge planning, care management, case management, or behavioral health in a remote setting, or equivalent combination of relevant education and experience.
• Registered Nurse (RN).
• Licence must be active and unrestricted in state of practice.
• Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements, unless otherwise required by law.
• Knowledge of or experience using the Care Transitions Intervention (CTI) or similar model.
• Background in discharge planning and/or home health.
• Demonstrated knowledge of community resources.
• Proactive and detail-oriented.
• Ability to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and personal situations.
• Ability to work independently, with minimal supervision and demonstrate self-motivation.
• Responsive in all forms of communication, and ability to remain calm in high-pressure situations.
• Ability to develop and maintain professional relationships.
• Excellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change.
• Excellent problem-solving, and critical-thinking skills.
• Excellent verbal and written communication skills.
• Microsoft Office suite/other applicable software program(s) proficiency.

Qualifications

• Transitions of care sub-specialty certification and/or Certified Case Manager (CCM).
• Hospital discharge planning or home health experience.

Skills

• Excellent computer skills and attention to detail.
• Excellent verbal and written communication skills.

Benefits

Not specified.

Pay

$26.41 - $51.49 / HOURLY

Schedule

Monday through Friday 8:30AM to 5:00PM EST (No weekends, no nights, no holidays, no call.)