Care Manager-RN TCM

JOB DESCRIPTION This role is eligible for a remote schedule (up to 2-days per week) upon successful completion of a 90-day probationary period. Job Summary: The Care Manager-Registered Nurse (RN) Transitional Care Management (TCM) is an integral part of the healthcare team. Demonstrates comprehensive and advanced knowledge related to Transitional Care by helping guide patients to receive the care that they need to prevent frequent hospitalizations. Utilizes, discretion and independent judgement to complete a comprehensive assessment on each referral ensure they meet the program qualifications. Identifies services needed and begins to develop a complex plan of care. Facilitates the participants access to care and coordinates medical appointments, medication refills, therapy sessions, treatment programs, and need for transportation. Continually assessing and reassessing participant needs, and changing condition updates plan of care as changes occur. Conducts follow-up telephone calls, and periodic in-home visits to check on participants and family evaluating services and the need for more services. Reinforces health education on, medications, disease process, encourages them to be active participates in the care they are receiving. Identifies barriers and takes steps for resolution of issues with speed and sensitivity, seeks assistance when necessary. Meets regularly with physicians, pharmacists and multidisciplinary healthcare team, homecare agencies, long term care facilities about participants' involvement in their care and progress towards a healthier life, ensures that the participants are getting the necessary services and identifies needs for additional services, and reviews and updates plan of care seeks input from team members for plan of care as needed. Works with healthcare teams, and agencies to strengthen the transitional care management program. Provides formal and informal education for community agencies, home care agencies, LTCF and the public about the TCM program. Maintains detailed information on each participant in case load, submits information as requested to leadership for review. Performs other duties as needed. Education and Experience: Bachelor's of Science degree in nursing (BSN). Minimum three years of experience in Care Management, Primary Care, or home care required. Experience working with older adults and families preferred. Knowledge and Skills: Advanced knowledge of care and utilization management practices and methodologies. Knowledge of aging process, common health issues, and related psychosocial issues. Basic knowledge of healthcare regulations and accreditation required. Strong assessment, problem solving, interpersonal skills. Able to: read; write legibly; speak in English (and Spanish preferred) with professional quality; use computer and software programs necessary to the position; troubleshoot and calibrate patient care equipment. Able to relate and communicate positively, effectively, and professionally with others; be assertive and consistent in following and/or enforcing policies; work calmly and respond courteously when under pressure; lead, supervise, teach, and collaborate; accept direction. Able to communicate effectively in English in person, in writing, and on the telephone; think critically; work independently with minimal supervision; perform basic math functions; manage multiple assignments effectively; work well under pressure; problem solve; organize and prioritize workload; recall information with accuracy; pay close attention to detail. Able to distinguish colors and smells as necessary for patient care; hear sufficiently for general conversation in person and on the telephone; identify and distinguish various sounds associated with the work place/patient care; see adequately to read computer screens, medical records, and written documents necessary to position; discern temperature variances through touch. Licensures and Certifications: California Registered Nurse (RN) Licensure required. Basic Life Support (BLS) certification issued by the American Heart Association required. Public Health Nurse certification preferred. ABOUT US Our mission is to continue the teaching and healing ministry of Jesus Christ. Our core values are compassion, excellence, humility, integrity, justice, teamwork and wholeness. ABOUT THE TEAM Loma Linda University Health is a Seventh-day Adventist, faith and values based Christian institution. Candidates must understand and embrace the mission, purpose, and identity of Loma Linda and its affiliated entities. We are an equal opportunity employer committed to the principles of diversity. We provide equal opportunities in all aspects of the employment process to every individual, regardless of gender, race, color, age, national origin, ancestry, physical or mental disability, marital or veteran status, genetic information or any other characteristic protected by law. In addition, we will provide reasonable accommodations for otherwise qualified individuals requesting an accommodation due to a disability. If you need accommodation assistance with accessing our job listings or completing an application, or during any other phase of employment with us, please contact Human Resources Management at View phone number on click.appcast.io. Loma Linda University Medical Center is a religiously-qualified Equal Opportunity Employer under Title VII of Civil Rights Act of 1964. No question on this application is asked for the purpose of unlawfully limiting or excluding any applicant's consideration for employment because of race, color, religion, gender, age, national origin, disability, genetic information, or any other status protected by applicable law. If you need a reasonable accommodation in the hiring process, please notify Human Resource Management. We appreciate your interest in Loma Linda and wish you success in your job search! #J-18808-Ljbffr Anacalifornia