Transitional Care Case Manager
Company: Complete Health
Location: Pell City
Posted on: January 27, 2023
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Job Description:
JOB SUMMARY:Under direction of the Primary Care Physician and
supervision of the Nurse Manager of Clinical Services, the RN
Transitional Care Manager is responsible to provide services for a
panel of Traditional Medicare and Medicare Advantage Plan patients
with medical and/or psychosocial problems who have had an emergency
room visit and/or skilled care inpatient admission. The timeframe
of Transitional Care Management is from the initial ER and/or
inpatient event to their return to independent or assisted living
as appropriate for their level of acuity. Transitional Care
Management services include non-face-to-face communication with the
patient and/or caregiver, hospital case manager, home health
agencies, specialist referrals, outside community and health
resources and assistance with scheduling the patient's follow up
with primary care provider and specialists.The TCM Nurse is
responsible to obtain and review the admission and discharge
documentation, medications, pending diagnostic tests and ordered
treatments. He/She provides assessment and support for treatment
regimen adherence, medication management, interaction with other
qualified health care professionals and education of patient and/or
caregiver to support and promote the patient's best ability for
self-management, activities of daily living and independent living.
The TCM Care Manager coordinates efforts with the Chronic Care
Managers to ensure that each patient's records are accurately
updated, including their problems list, diagnoses, health
conditions, mediations list and Care Team and bringing additional
medical concerns to the primary care provider as needed. The TCM
Care Manager assesses appropriate levels of acute care management
and timing for a smooth transition to Chronic Care
Management.Knowledge/Skills/Abilities:The TCM Care Manager must be
able to perform each essential duty satisfactorily. The
requirements listed are representative of the knowledge, skill,
and/or ability required.Must demonstrate personal effectiveness and
credibility, collaborative skills, communication proficiency and
flexibility. Must demonstrate strong decision making and
documentation skills.Possesses organizational and problem-solving
skills: Identifies and resolves problems in a timely manner;
gathers, analyzes and communicates information skillfully; develops
alternative solutions in an organized manner.Knows, understands and
works within the scope of his/her practice.Able to delegate
responsibilities appropriately to staff licensure, education, and
experience.Able to work independently and in a multidisciplinary
team.Keeps leadership informed and seeks advise and/or help from
management whenever needed.Able to manage difficult or emotional
customer service situations and responds to requests for customer
service and assistance in a timely and appropriate manner.Has
excellent written and oral communication skills.Uses reason and
speaks clearly, respectfully and persuasively in positive and
negative situations, focusing on resolving conflict.Shows respect
and sensitivity for cultural diversity, promotes a harassment-free
environment and fosters a non-discriminatory climate.Keeps
commitments; inspires the trust of others; works with integrity and
ethically.Adapts to changes in the work environment; demonstrates
willingness to change approaches or methods as needed to best fit
the situation within practice guidelines.Essential Duties and
Responsibilities:The TCM Care Manager follows and maintains a panel
of high acuity patients for transition of care from inpatient to
outpatient settings.Is responsible to coordinate and communicate
with providers, staff and patient's Care Team members (including
specialists, Case Managers and patient's family and/or
representative) regarding the patient's specific and appropriate
acuity level of care needed, as determined by their chronic
conditions, acute care events and social/living needs.Ensures that
the care patients receive is efficient, thorough, timely and is
properly documented to help patients avoid reoccurrences of ER and
urgent care visits and/or hospital readmissions.Assists in ensuring
the best quality of life possible for each patient in their
care.Works with the Nurse Manager of Clinical Services, the Quality
Improvement Manager and the MSRs to identify specific patient
social and preventative care needs.Facilitates resolutions when
possible with resources throughout an assigned geographic
area.Provides regular reporting of activities and statistical
status of the TCM patients in his/her care to the Nurse Manager of
Clinical Services as directed.The TCM Care Manager helps to fill in
for other Care Pod staff as needed.Participates in department
rotating " On-call" schedule determined by the Nurse Manager of
Clinical Services. Participates in pertinent meetings, workshops,
seminars, and related forums as directed.Maintains confidentiality
and follows HIPAA and OSHA guidelines. Maintains current Registered
Nurse License in the State of Alabama.Please note this job
description is not designed to cover or contain a comprehensive
listing of activities, duties or responsibilities that are required
of the employee for this job.Duties, responsibilities and
activities may change at any time with or without
notice.Requirements:EDUCATION AND EXPERIENCE REQUIREMENTS:Current
Alabama Licensed Registered Nurse (RN) and 3 years of related care
management, medical clinical experience and/or training is
required; equivalent combination of education and experience
considered as determined by the Director of Quality and/or Practice
Administration. To perform this job successfully, an individual
must have knowledge of Word Processing and internet software.
Athena EHR experience is Preferred. Reasonable accommodations may
be made to enable individuals with disabilities to perform the
essential functions.Skill Requirements: (X = Required for
job)Typing/computer keyboardVerbal communicationUtilize computer
software (specified above)Written communicationRetrieve and compile
information Public speaking/group presentationsMaintain
records/logsResearch, analyze and interpret informationVerify data
and informationInvestigate, evaluate, recommend actionOrganize and
prioritize information/tasks Leadership and supervisory, managing
peopleOperate office equipmentBasic mathematical concepts (e.G.
add, subtract)Advanced mathematical concepts (fractions, decimals,
ratios, percentages, graphs) Abstract mathematical concepts
(interpolation, inference, frequency, reliability, formulas,
equations, statistics)Physical Requirements: (X = Required for
job)Sitting for extended periodsLifting/carrying up to 20 pounds
various itemsStanding for extended periods Lifting/carrying more
than 20 pounds various itemsExtended periods viewing computer
screenRepetitive
MotionsWalkingPushing/PullingReadingsBending/StoopingSpeakingReaching/GraspingHearingWritingInner
office/clinic travel (mileage reimbursement provided)Other (List):
Hazards: (X = Required for job)Normal office environmentElectrical
current Toxic or caustic chemicals Housekeeping and/or cleaning
agents Flammable, explosive gases Proximity to moving mechanical
parts
Keywords: Complete Health, Birmingham , Transitional Care Case Manager, Executive , Pell City, Alabama
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