Transitional Care Case Manager

About the role

The Transitional Care Case Manager (TCCM) facilitates and coordinates appropriate referrals to the Transitional Care Clinic (TCC). The TCCM assists with managing the referral process, data collection, and ongoing coordination of patient care in the clinic. The TCCM also coordinates post-discharge contacts with indicated patients outside the clinic structure for readmission avoidance.

Responsibilities

• Collaborate with internal providers, CM/SW teams, and nursing to review TCC referrals.
• Evaluate patients' eligibility against TCC accepting criteria.
• Act as a liaison between the inpatient teams, the TCC, and patients and families throughout the referral period to coordinate the first post-discharge appointments.
• Establish TCC appointments and ensures patient/caregiver agreement with timing and location. Works with patient/caregiver to secure transportation if needed. Ensures the appointment information is available on the AVS.
• Completes post-discharge transitional care calls within 72 hours. Completes necessary documentation in EHR.
• Coordinates with internal and external resources any needs or concerns identified during post-discharge contact with patient/caregiver. Documents any updates to care plan in the EHR.
• Collaborates with the TCC Medical Director to complete and aggregate any data related to TCC patients, referrals, and ongoing care plans. This would include anything for the VBE or grant fund.
• Collaborates in presenting ongoing data to internal and external stakeholders when indicated.
• Remains in communication with TCC providers to assist with any clinical intervention or patient care education. Implements interventions focused on readmission and ED diversion.
• Works with TCC team to ensure hand-off to established or new primary care practices.
• Patriciates in clinical performance improvement activities focused on the goals of the TCC and VBE programs.
• Expands to non-TCC patents for transition of care tasks based on caseload and as designated by the CM leadership and VBE leadership.
• Adheres to departmental and hospital regulatory requirements specific to CM role. Works with TCC team to monitor Regulatory compliance in the clinic setting. Documents in the EHR per departmental and hospital standards for discharge planning and any post-acute discharge interventions.

Qualifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure Upon Hire - required
• Bachelor's Degree - preferred
• 4-6 years of nursing experience
• Min of 3 yrs in direct care nursing and/or case management
• Recent experience in case management, utilization management and/or discharge planning/home care in a high volume, acute care hospital - preferred
• Ability to multi-task with all roles assigned to the position
• Ability to work autonomously while collaborating with both inpatient and outpatient teams
• Demonstrates effective communication, facilitation, and organizational skills. Assertive and creative in problem solving, critical thinking skills, systems planning and patient care management. Self-directed with the ability to adapt in a changing environment
• Basic knowledge of computer systems with skills applicable to utilization review process

Physical Demands

• Standing - Constantly
• Walking - Constantly
• Sitting - Rarely
• Lifting - Frequently
• Carrying - Frequently
• Pushing - Occasionally
• Pulling - Occasionally
• Climbing - Occasionally
• Stooping - Frequently
• Kneeling - Frequently
• Crouching - Frequently
• Crawling - Occasionally
• Reaching - Frequently
• Handling - Frequently
• Grasping - Frequently
• Feeling - Constantly
• Talking - Constantly
• Hearing - Constantly
• Repetitive Motions - Constantly
• Eye/Hand/Foot Coordination - Constantly