Transitional Care Manager RN

Transitional Care Manager RN

Requirements

• An active RN license within the state of practice in good standing
• Willingness to obtain cross-state licensure, as needed
• Certified Case Manager (CCM) or equivalent case management certification required, or willingness to obtain within 12 months of hire
• 2+ years’ experience in transitional nursing, emergency room nursing, discharge planning or home health
• Knowledge of Medicare/Medicaid and NCQA regulatory transitions of care criteria
• Exceptional communication skills and customer service orientation
• Innovative and independent problem-solving skills
• Ability to monitor and evaluate opportunities for cost-effective care options with high-quality outcomes
• Valid driver’s license and ability to travel daily
• Working knowledge of Microsoft Office Product Suite
• US work authorization

Responsibilities

• Manage patients through transitions of care, either face to face in the facility or telephonically, within a defined geographical area and care setting
• Advocate for the patient throughout the care continuum to ensure access to resources and resolution to all barriers to care
• Identify opportunities for improved program workflows, increased internal and external partnerships, and higher quality patient care
• Maintain real-time and accurate records of patient status through care transitions within Oak Street’s internal inpatient platform
• Adhere to CMS, state specific and NCQA compliance criteria as related to Transitions of Care
• Evaluate patient status post-ED visit or observation stay through a clinical assessment and medical record review
• Triage to determine appropriate follow up care and next steps, including reviewing medication lists and scheduling follow up appointments with the appropriate provider and/or specialists
• Engage directly with inpatient physicians, case managers, medical directors, and hospitalists (where applicable) to facilitate safe and timely discharge, appropriate follow-up care, and next steps
• Coordinate with the Utilization Management team to review medical and payer records to ensure appropriate length of stay and identify any barriers to discharge
• Conduct structured clinical assessment to identify post-discharge needs, including but not limited to: medications, specialist appointments, home health, DME, caregiver support, social determinants of health, etc.
• Conduct medication reconciliation on behalf of the PCP
• Collaborate with other transitions team members (e.g. Transitional Care Managers – Social Work and Transitional Care Coordinators) to ensure safe discharge and timely follow up
• Communicate and coordinate with internal stakeholders to identify and address patient needs
• Participate in regular meetings with Oak Street Health Population Health leaders to coordinate program implementation and ongoing management
• Participate in initial and ongoing required training to ensure appropriate implementation of transitions activities and programming
• Follow program procedures for documenting and tracking transitions interventions

Preferred Qualifications

• Experience in utilization management preferred
• Additional language proficiency (Spanish) preferred but not required