Transitions RN Care Manager

About the Role

The Integra Transition Manager collaborates with a group of Physicians to pursue cost-effective, quality-focused management interventions by achieving predetermined financial and clinical outcomes. Responsible for providing ongoing communication with patients, continuing care coordinators, social workers, and physicians to ensure patients have appropriate resources and support in the community, intervening when patients cannot be managed adequately. Tracks patients along the continuum of care, identifies patterns that negatively impact cost and quality, and assists in developing plans to improve care.

Responsibilities

• Applies Case Management principles to the acute care inpatient population to ensure appropriate utilization of resources and level of care, including assessing, planning, implementing, coordinating, evaluating, and collaborating with the interdisciplinary team, patients, families, and community providers.
• Facilitates discharge planning for Integra ACO patients with Care Coordination who are in observation or admitted status from the acute care setting, including acute rehabilitation admission, transfer to a skilled nursing facility, initiation or resumption of visiting nurse services, referral to outpatient providers, transportation, and initiation of outpatient infusion therapy.
• Assists in the facilitation of patient flow with Care Coordination by identifying barriers and working with the interdisciplinary care team to improve outcomes.
• Identifies patients for Case Management and Social Service referrals during the review process.
• Completes all documentation in a timely manner in Epic and Cerner.
• Acts as a resource to the ED Hospital Liaison.
• Engages in process improvement activities focused on efficient care delivery and promotes positive clinical and quality outcomes, including reducing unnecessary admissions, readmission rates, and improving flow metrics.
• Protects and preserves patient confidentiality at all times.
• Performs related duties as required.

Requirements

• Registered Nurse with a Bachelor’s Degree in Nursing or equivalent, with a current RI license.
• Minimum of 5 years of related clinical Acute Care or Case Management experience.
• Knowledge of utilization review, quality assurance, discharge planning, third-party payor regulations, and community health.
• Demonstrated high-level interpersonal skills (oral and written), analytical skills, leadership abilities, and effectiveness within a team environment.

About Us

Care New England Health System (CNE) and its member institutions—Butler Hospital, Women & Infants Hospital, Kent Hospital, VNA of Care New England, Integra, The Providence Center, and Care New England Medical Group—is a trusted, integrated health care organization that fuels the latest advances in medical research, attracts top specialty-trained doctors, hones renowned services and innovative programs, and engages in important discussions about health and end-of-life wishes. Care New England is helping transform the future of health care and serves as a leading voice in efforts to ensure the health of the individuals and communities we serve.