Summary We are hiring for a Transitional Case Manager/ Discharge Case Manager at University of Maryland Medical Center Salary Range: RN $80,000-$90,000 full-time annual or LPN $75,000-$80,000 full-time annual At VNA of Maryland, a part of LHC Group, we embrace a culture of caring, belonging, and trust and enjoy the meaningful connections that come from it: for the whole patient, their families, each other, and the communities we serve—it truly is all about helping people. You can find a home for your career here. In a Transitional Care Manager role, you can expect: learning and development opportunities in the ever-evolving state of healthcare ways to cultivate relationships and educate patients, families, and colleagues on resources to help lead healthy, productive lives flexibility for true work-life balance company-wide support and resources to help you achieve your goals If you love nursing and want to strengthen your experience, this is a great opportunity for you. Apply today! Responsibilities The Transitional Case Managers(TCM) primary responsibility is to facilitate a seamless transition for patients discharging from a facility setting to the care of an LHC Group agency for post-acute care needs. Included and aligned within this responsibility is the understanding and implementation of company market development initiatives and their role in growth as we focus on serving more patients and delivering exceptional care. The TCM will verify home health orders, assess the care required, and ensure continuity of care and the agency's ability to meet the needs of the patient. This clinical liaison position will assess each patient to determine their level of health literacy and be adept at ensuring the patients and families are included in care planning. Following identification of needs the TCM will begin best practice intervention and education to improve patient outcomes and promote patient self-management. The TCM will implement rehospitalization reduction initiatives for patients with Acute Care Hospitalization risk and continually communicate between healthcare providers during all phases of transition from the facility into the home. Identifies primary care physician to follow the plan of care Educates patient on importance of the post facility discharge follow up appointment with the physician Assess patient’s risk for readmission using LACE tool and documents in Transition encounter Educates patient on homebound criteria and verifies patient meets these requirements Educates LHC Group referrals on Call First process and ensures patient and family have agency contact information Educates patient on obtaining all necessary prescriptions prior to discharge from hospital and confirms patient’s understanding of medication, pharmacy, and delivery method Coordinates other ancillary services for the patient (DME| Infusion) as needed Assists the LHC Group agency in preparation of accepting care of the patient post discharge Serves as a liaison between the LHC Group agency and all involved healthcare providers of newly referred patients as well as existing patients transferred to the hospital from the home health agency Communicates to discharge planning any active patients that transfer from home health into a Facility and coordinates resumption of care with patient prior to discharge if applicable orders are obtained Provides follow up feedback to case management team regarding status of readmissions and any non-admit decisions based on information provided to them by the LHC agency All other duties as assigned Education and Experience Experience Requirements Must have one year home health experience or one year of hospital case management experience. License Requirements Must have current RN or LPN or SW licensure in state of practice Reliable means of transportation and must have current driver's license and auto insurance Skill Requirements Must have excellent verbal and written communication skills with all members of the healthcare team Must have excellent organizational skills and ability to complete competing priorities Must have thorough understanding of home health qualifying criteria and coverage guidelines Proficient computer skills. Company OverviewLHC Group is committed to a culture of diversity, equity and inclusion and is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any legally other protected characteristic. VNA of Maryland Owings Mills a part of LHC Group family of providers – the preferred post-acute care partner for hospitals, physicians, and families nationwide. We deliver high-quality, cost-effective care that supports our patients when and where they need it. From our home health, hospice, and community-based services to inpatient care at our clinics and hospitals, our mission is to reach more patients and families with effective and efficient healthcare. More hospitals, physicians, and families choose LHC Group because we are united by a single shared purpose: It's all about helping people.