Company: Oak Street Health
Title: Transitional Care Manager, RN
Multiple Locations: University of Pennsylvania Hospital and Penn Presbyterian Medical Center
Company Description
Oak Street Health is a rapidly growing company of primary care centers for adults on Medicare in medically-underserved communities where there is little to no quality healthcare. Oak Street's care is based on an entirely new model that is based on value for its patients, not on volume of services. The company is accountable for its patients' health, spending more than twice as long with its patients and taking on the risks and costs of their care. For more information, visit http://www.oakstreethealth.com.
Role Description:
Oak Street Health takes a team-based approach to providing outstanding patient care. Transitional Care Manager - RN (TCM-RN) is an integral part of the team. The TCM-RN is the primary member of the Oak Street clinical care team and facilitator of interdisciplinary collaboration and care continuity across care settings and systems, empowering the patient and/or caregiver to play an active and informed role in post-ED/Observation and post-hospitalization care plan execution. The TCM-RN's role is to provide information and support for the patient in identifying and addressing problems and building relationships with providers and care teams in various sites of care (e.g., ED, hospital, SNF, Oak Street Health clinics).
This role prioritizes the relationship with the patient/family; providing high-quality, patient-centered care; preventing avoidable readmissions; and managing efficient resource utilization.
Core Responsibilities:
Transitions Management
Manage patients through transitions of care, either face to face in the facility or telephonically, within a defined geographical area and care setting.
Advocate for the patient throughout the care continuum to ensure access to resources and resolution to all barriers to care.
Identify opportunities for improved program workflows, increased internal and external partnerships, and higher quality patient care.
Maintain real-time and accurate records of patient status through care transitions within Oak Street's internal inpatient platform.
Adhere to CMS, state specific and NCQA compliance criteria as related to Transitions of Care.
Depending on the clinical scope of the transitions program in specific regions, transitions management responsibilities may also include:
Emergency Department and Observation Stays
Evaluate patient status post-ED visit or observation stay through a clinical assessment and medical record review.
Triage to determine appropriate follow up care and next steps, including reviewing medication lists and scheduling follow up appointments with the appropriate provider and/or specialists.
Hospital Inpatient Stays
Engage directly with inpatient physicians, case managers, medical directors, and hospitalists (where applicable) to facilitate safe and timely discharge, appropriate follow-up care, and next steps.
Coordinate with the Utilization Management team to review medical and payer records to ensure appropriate length of stay and identify any barriers to discharge.
Assist Utilization Management team with access to external medical record information (if available) when needed to make appropriate determinations.
Establish relationships and ensure patient/family are informed of patient condition, plan of care and discharge plan, all discharge instructions, medication reconciliation; rationale of Utilization Management determinations and any financial information associated with such, potential for LTC transition (if applicable) and importance of timely PCP follow-up following discharge.
Post-Discharge from an Inpatient or Post-Acute Stay
Conduct structured clinical assessment to identify post-discharge needs, including but not limited to: medications, specialist appointments, home health, DME, caregiver support, social determinants of health, etc.
Conduct medication reconciliation on behalf of the PCP.
Address identified post-discharge needs directly or via collaboration with other team members .
Collaboration and Communication with Internal Stakeholders
Collaborate with other transitions team members (e.g., Transitional Care Managers - Social Work and Transitional Care Coordinators) to ensure safe discharge and timely follow up.
Communicate and coordinate with internal stakeholders to identify and address patient needs (e.g., care team, social work, behavioral health, utilization management, Hard-to-Reach, Central Telehealth, etc.).
Participate in regular meetings with Oak Street Health regional leaders to coordinate program implementation and ongoing management.
Collaboration and Communication with External Stakeholders
Participate in regular meetings with the Program Director and other Transitional Care Managers on programmatic development and clinical learning.
Identify partnership development opportunities and systems improvements.
Coordinate with Regional Leaders and hospital partners to implement system improvements.
Documentation, Tracking, Reporting and Training
Participate in initial and ongoing required training to ensure appropriate implementation of transitions activities and programming.
Participate with the TCM Lead in quality assurance activities.
Follow program procedures for documenting and tracking transitions interventions.
Adhere to CMS, state, and NCQA compliance criteria as related to Transitions of Care.
Other duties, as assigned.
What are we looking for?
An active RN license within the state of practice in good standing
Willingness to obtain cross-state licensure, as needed
Nurse Case Management Credentialing (RN-BC) or Certified Case Manager (CCM) required, or willingness to obtain within 12 months of hire
Minimum of 2 years of experience in transitional nursing, emergency room nursing, discharge planning or home health
Experience in utilization management preferred
Knowledge of Medicare/Medicaid and NCQA regulatory transitions of care criteria
Exceptional communication skills and customer service orientation
Innovative and independent problem solving skills
Ability to monitor and evaluate opportunities for cost-effective care options with high-quality outcomes
Spanish-speaking preferred but not required
A flexible, positive attitude
Access to reliable transportation and ability to travel daily
Working knowledge of Microsoft Office Product Suite
US work authorization
Someone who embodies being 'Oaky'
What does being 'Oaky' look like?
Radiating positive energy
Assuming good intentions
Creating an unmatched patient experience
Driving clinical excellence
Taking ownership and delivering results
Being scrappy
Why Oak Street?
Oak Street Health offers our coworkers the opportunity to be at the forefront of a revolution in healthcare, as well as:
Collaborative and energetic culture
Fast-paced and innovative environment
Competitive benefits including paid vacation and sick time, generous 401K match with immediate vesting, and health benefits
Oak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply to oakstreethealth.com/careers.