RN Case Manager – Transitions of Care

RN Case Manager – Transitions of Care

Requirements

• Active, unrestricted Registered Nurse license in home state and willingness and certification in good standing and the ability to get licensed in requested states such as Michigan, Colorado or Massachusetts within 90 days of hire date.
• 3+ years of experience providing clinical services to Adult and/or Geriatric individuals with co-occurring chronic medical and behavioral health conditions, particularly in virtual settings.
• Demonstrated ability to help a patient adapt new habits, change behaviors, and motivate towards achieving health goals.
• Comfort with electronic medical record documentation and excited about how technology can support your work and drive ongoing improvement towards new and better care
• Experience and comfort working within an interdisciplinary care team, and specifically communicating with clinical and non-clinical team members.

Responsibilities

• Providing post-discharge follow up care for patients virtually via video, telephone, or text
• Providing patients with education on their care plans and medications.
• Effectively interpreting and utilizing electronic data tools and analysis to organize daily activities and provide high quality of care
• Collaborating closely with local Accompany Health teams to ensure continuity of care
• Establishing and fostering trusting relationships with your patients and ensuring that care is appropriately aligned with their goals and values
• Collaborating with external hospitals when necessary to collaborate on discharge planning and advocate for patient care aligned with their goals
• Providing feedback on program design and workflows to ensure we are providing the best patient care possible.
• Timely and appropriate documentation.
• Roles and responsibilities may evolve as our care model develops.
• Occasional in person team building time

Preferred Qualifications

• Experience in adult internal medicine, family medicine, geriatrics, palliative care, and virtual care.
• Experience in transitions of care management for patients being discharged from hospitals, skilled nursing facilities, and behavioral health facilities, including performing detailed medication reconciliation, patient education, and connection/navigation to appropriate services.
• Experience in behavioral health settings and/or caring for patients with serious mental illness and/or substance use disorder.
• Experience in trauma-informed care and practices.
• Experience as an active participant in continuous quality improvement projects.
• Experience in value-based care organizations