The RN Care Manager-Transitions of Care is a member of the population health team focused on coordination of care of patients in transition between the hospital, emergency department, skilled nursing facility (SNF), and primary care setting. Primary responsibility includes working with teams within our local hospitals, health plans, SNFs, community based organizations (CBOs), and Tiburcio Vasquez Health Center (TVHC) to keep patients healthy upon their return home. Through this work, we will be able to prevent unnecessary readmissions and emergency department visits post-discharge. Under the general direction of the Senior Director of Population Health, the RN Care Manager-Transitions of Care monitors the daily ADT (admissions, discharges, and transfers) information to identify patients in need of post-discharge follow up and facilitates care with the assigned care teams, specialists, and CBOs.

The RN Care Manager-Transitions of Care may oversee clinical care as compatible with their licensure including monitoring of duties performed by MA staff.

Compensation: $42.67 - $48.03 per hour, depending on experience.

Responsibilities:

Identifies patients discharged from inpatient units, skilled nursing facilities, and emergency departments through the electronic health record (EHR) as well as through information from our health plans. Conducts outreach to patients and families to assess patient needs, understanding of medications, discharge instructions, and needed support utilizing evidence-based resources and tools. Coordinates interventions across medical and behavioral health areas focusing on patient-centered autonomy and assisting the patient in defining goals. Facilitates a post discharge visit in conjunction with a team scheduler at a timeframe appropriate for the patient’s condition and acuity. Analyzes and tracks inpatient admissions, readmissions, emergency visits, and patient outcomes to address process improvement. Works collaboratively with the patient and the physicians, care management team, behavioral health team, integration team, and population health leadership to identify any barriers affecting timely patient care and to activate and meaningfully partner. Aligns resources with the patient including referrals to other disciplines of the care management team, home care, community resources, and other healthcare providers. Advocates for patients and families across the care continuum. Provides regular feedback and education across teams at TVHC Actively participates in meetings, multi-disciplinary care team conferences, huddles, and discipline specific team meetings. Maintains timely and complete medical record documentation and billing, as appropriate, of all care management encounters. Works with internal and external stakeholders continuously evaluate processes and develop improvements to advance the care management program. Adheres to the scope of practice for Registered Nurses per state regulatory guidelines. Effectively participate in various internal committees and performs other duties as requested.