Transitional Care Manager

Duties And Responsibilities

• Meet with members during their inpatient admission and develop a person-centered care plan (PCCP) to address their discharge and care transition needs.
• Call members post discharge to review discharge instructions, complete medication reconciliation and ensure scheduling of hospital follow-up visits.
• Coordinate member post discharge plans including hospital follow-up with primary care provider and specialists, home health, durable medical equipment, medications, social and caregiver supports.
• Communicate with AbsoluteCare team and community primary care providers on a regular basis, review assigned member discharge plans and barriers to a safe discharge.
• Manage PCCP and member contact in compliance with all agency requirements, internal protocols, and accreditation standards.
• Provide education with teach back regarding medical, behavioral, and functional health conditions, symptoms, and treatment options.
• Provide evidence-based clinical interventions centered on established person-centered care plan goals using a variety of approaches, e.g., trauma informed care, harm reduction, behavior change modalities, motivational interviewing, teach back methods and problem solving.
• Attend clinical rounds with health plan partners, review PCCPs for discharge, provide recommendations for appropriate level of care and next steps to expedite care transitions.
• Meet established Key Performance Indicators.
• Manage assigned caseload based on visit and contact frequency requirements and utilization data.
• Proactively mitigate/resolve barriers to care to increase adherence to discharge plan and reduce risk of readmission.
• Aid members in accessing and engaging with AbsoluteCare and community services and resources and follow up on member adherence to referrals.
• Actively participate in required meetings.
• Maintain the security and privacy of all information that is owned by AbsoluteCare or maintained on behalf of the company’s patients, employees, and business partners.

Minimum Qualifications

• Willing and able to travel up to 80% of the time to local area hospitals, skilled nursing facilities and residential treatment facilities to visit members and build relationships with discharge planners and case management staff.
• Licensed RN by the state in which practicing and abide by all laws, regulations, and requirements.
• Preference given to RN candidates with extensive experience discharge planning, care transition coordination and medical and behavioral case management in the community.
• Candidate with CCM or CCTM credentials a plus.
• Active CPR certification.
• 3+ years of experience in serving the needs of complex populations, including medically complex, trauma history, mental health conditions, substance abuse, and socioeconomic barriers in an office or community-based setting.
• Preference given to qualified candidate with multiple settings experience (Inpatient, LTPAC, home health, corrections, community programs and/or human service agencies).
• Experience with complex government-sponsored populations preferred, e.g., Medicaid, Medicare beneficiaries.
• Experience with member engagement, transitions of care, clinical care, and/or case management.
• Experienced in discharge planning and care coordination for continuity in care transitions, strategies for reducing readmissions and chronic condition management interventions a must.
• Familiarity with MCG and ASAM criteria a plus.
• Ability to take a creative and innovative approach to problem-solving to aid patients in overcoming barriers to care transitions.
• Excellent computer skills including Microsoft Office Suite (Outlook, Excel, PowerPoint, Word) and electronic medical record documentation required.
• Excellent written and oral communication skills to interact with members, families, community stakeholders, and interdisciplinary team required.
• Ability to meet accreditation and quality standards including, but not limited to NCQA, PCMH, HEDIS through following defined procedures to assess, intervene and document interactions.
• Ability to work independently and exercise excellent clinical judgement.
• Active unencumbered driver’s license, with automobile insurance, reliable transportation, and ability to work in office and in the community.
• Second language ability is desirable relevant to local population, geography, resources.