Transitions of Care RN Care Manager

About the role

As an integral member of the Population Health Management Operations team, the Transition of Care Nurse Care Manager provides episodic care management for Medicare Shared Savings Program (MSSP) and Medicaid ACO patients from inpatient admission to home. This includes follow-up phone calls after discharge, medication reconciliation, and ensuring patients have appropriate follow-up appointments scheduled, as well as documenting and ensuring all billing requirements are met prior to submitting TCM charges. The role interfaces directly with patients (via phone), primary care physicians, pharmacists, care managers, and healthcare teams involved in patient care, and collaborates with PHM Clinical Operations leadership.

Responsibilities

• Manages episodic transitions of care for Medicare Risk and Medicaid risk patients from inpatient discharge to home.
• Calls all discharged patients within two business days of discharge and conducts post-discharge assessments.
• Works alongside the PHM Clinical Pharmacist to identify and perform medication reconciliation for identified patients within the two-day follow-up phone call.
• Reviews discharge instructions/paperwork prior to calls to review with patients any action items needed prior to follow-up appointments.
• Facilitates face-to-face follow-up appointments with primary care providers within 7–14 days after discharge (or according to discharge instructions if applicable).
• Documents patient interactions (phone calls) in the appropriate patient chart in the electronic medical record.
• Manages and coordinates transitions of care by communicating the care plan to other providers, care managers, and applicable practice staff.
• Maintains all documentation according to standards and requirements.
• Ensures all Transitions of Care (TCMs) meet appropriate billing requirements prior to submitting documentation to the billing department.
• Demonstrates effective teamwork and collaboration with the primary care provider and the care team.
• Engages the patient and caregiver as active members of the care team and facilitates an organized and effective warm handoff for transitions of care back to the patient’s medical home (PCP).
• Participates in regular meetings with providers and the care team to identify opportunities for better transitions or to modify workflows as needed.
• Communicates with other PHM and Regional Service Operation (RSO) departments and sites to foster collaboration as a system around the patients served.

Organizational Responsibilities

• Demonstrates a positive attitude in dealing with patients, coworkers, and other healthcare providers and in addressing problems and/or crisis situations.
• Works independently as well as functions effectively within a team-based model of care.
• Establishes collegial relationships with physicians, office staff, and healthcare providers in physician offices, community agencies, hospitals, and other healthcare facilities.
• Within the patient-centered model of care, demonstrates a commitment to meeting the patient’s needs and expectations.
• Within the team-based model of care, demonstrates initiative and creativity to continuously improve services, work processes, and other activities that affect quality and utilization.
• Follows applicable policies and procedures for general safety, fire safety, infection control, attendance, punctuality, and appearance.
• Performs all duties as assigned.

Other Duties and Responsibilities

• Assumes accountability for professional growth and development.
• Acts as a role model for patients by practicing behaviors consistent with the program goals of health promotion and disease prevention.
• Identifies quality of care issues and reports concerns to the appropriate person.
• Collects, prepares, and reports data as directed.
• Assists in preparation for external audits and surveys as applicable.

Requirements

• Associate’s Degree in Nursing (ASN) or Bachelor’s Degree in Nursing (BSN).
• RN License for State of MA.
• 3+ years of experience in hospital, health plan, or community case management or utilization management role.
• Care management or home care background.
• Managed care or previous healthcare reimbursement knowledge.

Preferred Qualifications

• Understanding of diagnostic criteria for dual conditions and the ability to conceptualize modalities and placement criteria within the continuum of care.
• Certification in Case Management (CCM) and/or other applicable professional certification preferred.
• Previous experience working in a post-acute setting such as LTAC, acute rehabilitation, skilled nursing facility, or home care.
• Bedside nursing experience.

Skills and Abilities

• Excellent organizational skills.
• Excellent oral, written, and telephonic skills and abilities.
• Critical thinking and problem-solving ability.
• Demonstrated ability to present and speak in front of groups.
• Demonstrated competency working with healthcare setting computer systems.
• Competence in Microsoft Word, Excel, and PowerPoint.
• Ability to work effectively with physicians and their staff in a physician practice setting.
• Ability to work a flexible schedule including some required evenings or early mornings.
• Knowledge of levels of care and the continuum of healthcare services.
• Ability to handle routine work, unexpected priorities, and multitask.
• Requires autonomy in decision-making using sound judgment based upon factual information, clinical experience, and nursing process.
• Ability to work with various practice sites.

Schedule

Full-Time, Saturday through Wednesday, standard business hours (approximately 8:30 AM–5:00 PM ET), with some flexibility with hours on weekends. Remote with ability to travel to Assembly Row in Somerville, MA for team-building, best practice sharing meetings, and/or events.

Pay

$58,656.00 – $142,448.80 per year.