Transition of Care Nurse Care Manager

Job Description

Job Description

JOB SUMMARY

A Transitional Care Nurse oversees the care of a patient as they move from one health care facility, such as a hospital or nursing home, to another facility or their home. The transitional care nurse ensures the relocation is as smooth as possible and helps the patient remain comfortable during the change. The transitional care model (TCM) of health care aims to reduce disruption in care, and thus lower the chances of patients relapsing and having to return to the hospital.

RESPONSIBILITIES

• Coordinate discharge planning with the inpatient member’s clinical team at admission and will follow through to ensure safe discharge.
• Coordinates with our utilization management team to review clinicals to ensure the member is progressing well and to determine an appropriate discharge plan. This includes but is not limited to ensuring a follow up is made with appropriate health care providers, ensuring members have access to prescribed medications, and that the member has adequate resources and equipment to meet their needs once the Member transitions to the community.
• Act as a patient advocate by negotiating for and coordinating resources with payers, agencies and vendors as appropriate.
• Provide education to physicians, care managers and other members of the team on the issues related to utilization review including inappropriate admissions and placements.
• Assist hospital staff in creating the discharge plan that will address identified needs and barriers to support a smooth recovery; assess if the member can be discharged.
• Conduct outreach and engagement post hospitalization, E.R visit or Skilled Nursing stay within 24 hours after Member’s discharge to assist members with medication reconciliation, medication compliance and to ensure member follows up with MD within a week after discharge.
• Documents progress notes regarding member’s condition and documents communications as it pertains to Member’s discharge plan in USFHP computer data base.

EXPERIENCE

• Minimum 2 years of Medical Surgical experience.
• Utilization review processes.
• Discharge planning and case management experience.

Skills/Competencies

• Flexible and willing to work in a dynamic and evolving role according to individual Members and program demands.
• Proactive team player.
• Strong follow through.
• Quick decision-making abilities.
• Strong problem solver.
• Experience in UM review.

Education/Certifications/License