Care Manager, Transitions of Care
Medical Home Network
full-time
Posted on:
Location Type: Remote
Location: Remote • 🇺🇸 United States
Visit company websiteJob Level
Mid-LevelSenior
About the role
- Engage with patients during hospitalization focusing on reasons for hospitalization, reinforcing care management plan of care, updating information for the Medical Home Care Management team, plan of care post-discharge, and goal setting
- Complete assessments as appropriate, such as risk screenings, initiate Care Plan, TOC Bundle, and others as needed
- Educate and support patients in health literacy, medication management, plan for follow-up and ongoing care, signs and symptoms of worsening conditions, functional or social needs, home and community-based services, advance directives, and other issues as identified
- Interface with hospital care team including nurses, social workers, case managers, hospitalists, and other staff responsible for utilization management and discharge planning
- Assess patient readiness for change and work with care team to ensure patients discharge to proper services and identify/address barriers to assure efficient and complete transitions of care
- Participate in care team meetings and Integrated Care Team collaboration as necessary
- Develop relationships with staff in inpatient hospitals (general acute and behavioral health) and Medical Home Care Management staff; gather and share medical home and discharge planning information between hospital and medical home
- Work with the patient and medical home to secure timely follow-up appointments
- Communicate and document activities and outcomes to the patient’s medical home care manager regularly
- Assist in leading transitions of care trainings for care management staff
- Participate in quality improvement initiatives as identified
- Other duties as assigned
Requirements
- Bachelor of Science in Nursing or Master’s Degree in Social Work LSW/LCSW
- Current state licensure as RN, LSW, or LCSW required
- Minimum of 3-5 years of recent work in care management, safety net/public health hospitals, FQHCs, academic medical centers, ambulatory care, physicians’ group, professional practice, and/or experience working in Community Mental Health Centers, outpatient mental health services; or combination thereof
- Knowledge of and experience with systems used to improve population health and management of disease states such as diabetes, heart failure, COPD/asthma, mental health, and substance use
- Excellent oral, written, and interpersonal communication skills
- Ability to work independently and as part of a team with a wide range of individuals from a variety of care delivery sites and community agencies
- Excellent organizational skills and ability to be self-driven
- Knowledge and experience with electronic information systems (EHRs, care management platforms)
- Experience in program development and training/education
- Proficient computer skills
- Nurse Case Management Credentialing (RN-BC) or Certified Case Manager (CCM) desirable
- Certified Alcohol and Other Drug Counselor (CADC) desired
- Knowledge and experience working with Medicaid and Medicare populations desirable
- Bilingual in Spanish preferred
Benefits
- Fun, challenging, and collaborative work environment with passionate colleagues that care deeply about healthcare delivery.
- Recognized as One of the Best Places to Work in Healthcare by Modern Healthcare.
- Competitive benefits programs including Medical, Vision, Dental, HSA, FSA, and 401k.
- Fitness reimbursement, commuter benefits, and tuition assistance.
- Great work life benefits- Paid time off, sick time, and 12 paid holidays.
- Remote position
- This role will require working 1 weekend a month.
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
care managementrisk screeningshealth literacymedication managementtransitions of careprogram developmenttraining/educationpopulation health managementdisease managementEHRs
Soft skills
interpersonal communicationorganizational skillsindependenceteam collaborationself-drivenpatient educationrelationship buildinggoal settingdocumentationquality improvement
Certifications
RN-BCCCMCADC