Transition Care Specialist

At Memorial Hermann, we pursue a common goal of delivering high quality, efficient care while creating exceptional experiences for every member of our community. When we say every member of our community, that includes our employees. We know that when our employees feel cared for, heard and valued, they are inspired to create moments that exceed expectations, while prioritizing safety, compassion, personalization and efficiency. If you want to advance your career and contribute to our vision of creating healthier communities, now and for generations to come, we want you to be a part of our team.

Job Summary

The Transitional Care Specialist (TCS) is responsible for providing transitional care management services to patients within risk-based payment programs, Memorial Hermann Community Based Transtional Care program (CBTC), Memorial Hermann contracted services (LOA) program or other identified complex case program. The TCS will manage and support assigned populations with moderate to complex care needs throughout a defined period of time or episode of care with the purpose of improving health outcomes and resource utilization through a coordinated approach. The TCS works in collaboration and continuous partnership with patients and their family members, as well as provider clinics, hospitals and post-acute partners, along with community resources, to achieve the desired outcomes. The TCS will use a defined process to receive patients/members that are identified as a member of one of these established populations, establish care plans and goals, and coordinate care and services throughout the continuum of care. The goal of the TCS is to enhance patient health and well-being, improve adherence to established care plans, and ensure appropriate utilization of resources. The TCS is knowledgeable and experienced in applying the skills necessary to provide care management services appropriate to the patient/member being served.

Job Description

MINIMUM QUALIFICATIONS

Education : Graduate of an accredited school of professional nursing required, BSN preferred or graduate of an accredited Master of Social Work program (MSW)

Licenses/Certifications:

• Current and valid license to practice as a Registered Nurse (RN) in the State of Texas or current and valid license as a Licensed Master Social Worker (LMSW) or Licensed Clinical Social Worker (LCSW) in the State of Texas required

• Certification in case management (CCM or ACM) or other area related to chronic disease management or population health preferred, such as CCP, CPUR or CCTM

Experience / Knowledge / Skills:

• Three (3) years of relevant clinical experience required, with at least two (2) years of experience in a care coordination and planning role with complex populations.

• Experience working in interdisciplinary teams.

• Excellent computer skills.

• Excellent communication and interpersonal skills with a demonstrated ability to actively engage patients and families in positive relationships.

• Demonstrated understanding of growth and developmental principles across various life cycles as it relevant to different age demographics.

PRINCIPAL ACCOUNTABILITIES

• Manages and supports an assigned population with moderate to complex care needs throughout a defined episode of care.

• Navigates patients through the care continuum with the goal of preventing readmissions and ensuring that care is provided at the right time, place, person and location.

• Development of a patient-centered, holistic plan of care through the use of disease-specific pathways tailored to eliminate barriers to care and meet treatment plan goals. Collaborates with treatment teams to coordinate safe and efficient discharges to the appropriate preferred network.

• Serves as a key member of the multi-disciplinary team, facilitating referrals to other interdisciplinary team members such as social workers, community health workers, pharmacy, behavioral health and health coaches in order to provide ongoing care coordination. 

• Increases continuity of care by building and facilitating effective and collaborative relationships with post-acute providers, physicians, and community resources. Provides Care Management services to assigned patients face-to face and telephonically. Travels to provider offices, patient homes and post-acute settings may occasionally be required.

• Engages and coordinates with the patient and/or patient’s designated family/caregivers to help resolve barriers to care.

• Advocates for patients to receive relevant and appropriate community resources.

• Manages effective transitions in care by facilitating warm hand-offs with the interdisciplinary team, physicians, and partners in the community.

• Promotes and coordinates timely access to appropriate care, including discharge follow up appointments.

• Facilitates effective and efficient utilization of clinical resources.

• Increases comprehension and health literacy through appropriate education that is tailored to the patient’s preferred learning methods.

• Provides education and coaching regarding chronic disease/s, self-management, community resources, etc. to support and empower patients to take a more active role in managing their health, well-being and shared decision-making.

• Coordinates warm hand-off to member’s primary care provider upon successful completion of the program.

• Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.

• Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.

• Demonstrates commitment to caring for every member of our community by creating compassionate and personalized experiences. Models Memorial Hermann’s service standards by providing safe, caring, personalized and efficient experiences to patients and colleagues.

• Other duties as assigned.