Transition of Care
4 weeks ago
Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.
Our Heart At Work Behaviors support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.
Help us elevate our member care to a whole new level Join our Aetna Team as an industry leader in serving dual eligible populations by utilizing best-in-class operating and clinical models. You can have life-changing impact on our members, who are enrolled in Care Management and present with a wide range of complex health and social challenges. With compassionate attention and excellent communication, we collaborate with members, providers, and community organizations to address the full continuum of our members' health care and social determinant needs. Join us in this exciting opportunity as we grow and expand our Care Management Programs to change lives in new markets across the country.
The Transition of Care Coach is responsible for care coordination of our members who are experiencing a significant change in health status which has resulted in the necessity of an emergency department visit, inpatient, skilled nursing, or rehabilitative stay. Under the direction of a Registered/Licensed RN, the TOC Coach ensures the member experiences a seamless transition to their next care setting and facilitates post-discharge goal attainment by:
- Complete post-discharge questionnaire, which may be market specific.
- Ensures the member has filled/received their medication(s) and has an understanding on how to take their ordered medications.
- Benefit education
- Monitor members in low CM level for alerts or changes in condition to be transitioned back to RN.
- Complete post discharge call and required assessments (RAP), medication reconciliation (if within scope of practice), fall assessment if fall risk identified.
- Complete inpatient confinement calls and monitoring for discharge.
- Management of warm transfers form concierge and engagement hub
- Provides clinical assistance to determine appropriate services and supports due to member’s health needs (including but not limited to: Coordination with PCP and Specialty providers, Condition Management information and education, Medication management, Community Resources and supports)
- Evaluation of health and social indicators
- Identifies and engages barriers to achieving optimal member health.
- Facilitates overall care coordination with the care team to ensure member achieves optimal wellness within the confines of the member’s condition(s) and abilities to self-manage.
- Coordinates post-discharge meal delivery, assists with securing DME, and helps to ensure timely physician follow-up.
- Understands Payer/Plan benefits, policies, procedures, and can articulate them effectively to providers, members, and other key personnel.
Our TOC Coaches are frontline advocates for members who cannot advocate for themselves. The TOC team will review prior claims to address potential impact on current case management and eligibility status. Focus assessments and/or questionnaires are designed to use a holistic approach to identify the need for a referral to clinical resources for assistance in functionality.
**RESPONSIBILITIES**
- Responsible for completing outreach cadence calls and post-discharge questionnaires within required compliance driven timelines.
- Utilizes weekly and daily reporting to identify utilization for the purpose of reducing Emergency Department Utilization and 30-day hospital readmissions.
- Follows members identified as inpatient in hospitals (whether planned or unplanned admission) and then throughout the subsequent care continuum until member can return to prior level of functioning in the community.
- Facilitates Interdisciplinary Care Team Meetings with Social Services, Care Management, PCP and other key players to discuss service needs and support safe transitions.
**Required Experience**
- Required: 2+ years LPN nursing experience
- Unrestricted and active Compact LPN/LVN licensure
**Preferred Experience**
- Preferred: 3+ years LPN nursing experience
- Self-motivated, energetic, detail-oriented, highly organized, tech-savvy Licensed Practical Nurses
- Discharge planning
- Advanced proficiency in Microsoft Word, Excel, and Outlook
- Ability to multitask, prioritize, and effectively adapt to a fast-paced changing environment while providing outstanding care.
- Effective verbal and written communication skills
- Bilingual a plus
**Education**
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