Acute Transition Care Management RN

Vaya Health is seeking a highly skilled and compassionate Acute Transition Care Management RN to join our team. As a key member of our care management department, you will play a vital role in ensuring the seamless transition of patients from acute care settings to community-based care.

The Acute Transition Care Management RN is responsible for providing proactive intervention and coordination of care to Vaya Health members and recipients who are receiving care in an inpatient community hospital or emergency department. You will work closely with the member and care team to identify and alleviate inappropriate levels of care or care gaps through assessment, multidisciplinary team care planning, linkage and/or coordination of services needed by the member across the MH, SU, intellectual/developmental disability, traumatic brain injury, physical health, pharmacy, long-term services and supports, and unmet health-related resource needs networks.

• Conduct or ensure all elements of transitional care management are implemented for members during physical health inpatient stay.
• Proactively identify Vaya members and ensure assignment to TCM or CC to manage the transition.
• Meet with members to conduct transitional care management and gather information on their overall health, including behavioral health, developmental, medical, and social needs.
• Provide transition planning for members not already engaged in Tailored Care Management.
• Use clinical skills and expertise to review clinical assessments and transition plans conducted by providers to ensure all areas of the member's transitional care needs are addressed.
• Work in an integrated care team including, but not limited to, doctors and pharmacist along with the member to address needs and goals in the most effective way ensuring that member/LRP could decide who they want involved.
• Link members to appropriate follow-up services including physical health, pharmacy, behavioral health, and other identified social determinate of health needs.
• Ensure that the care plan includes a transition plan developed by care team or, if necessary, by the ATCM, RN to meet needs and to access care for the individual.
• Convene key providers and others to address needs of the individual including participation in in-person or telephonic treatment team meetings, while the member is still in the facility.
• Support and assists with education and referral to prevention and population health management programs.
• Coordinate Diversion efforts for members at risk of requiring care in an institutional setting.
• Visit, or make best effort to contact, the member during their stay in hospital and be, or be sure a member of the care team, is present on the day of discharge when possible.
• Identify gaps in services and supports, intervenes to ensure that the member receives and can access appropriate care.
• Measure results of intervention and treatment, including reduction a high-risk events and inappropriate service utilization.
• Ensure that services are coordinated across the Vaya Health system and with other systems, including primary care, Opportunities for Health services and supports, social determinants of health, nursing facilities, and/or specialist.
• Ensure development of a written discharge plan through a person-centered planning process in which the member has a primary role and which is based on the principle of self-determination. Include the discharge plan in the member's care plan.
• Provide clinical transition planning assistance to local community hospitals, and coordinates with care team, and tracks those discharged from local hospitals to ensure timely follow up with aftercare services to prevent further hospitalizations.
• Assist the member in obtaining needed medication/prescriptions prior to discharge, ensure an appropriate care team member conducts medication reconciliation/management and support medication adherence.
• Develop or begin development of a ninety (90) day post-discharge transition plan prior to discharge from physical health inpatient settings, in consultation with the member, facility staff, and the member's care team, that outlines how the member will maintain or access needed services and supports, transition to the new care setting, and integrate into their community.
• Ensure that any barriers preventing the member from being discharged and transitioning into the chosen integrated setting are recorded in the member's Care Plan and actively seek solutions for addressing those barriers.
• Ensures all required documentation is completed and submitted by inpatient facility for member's transitioning to a Skilled Nursing Facility (SNF) due to complexity of cases, for ensures timely transition to SNF.
• Comply with Continuity of Care and Tailored Care Management continuum and Vaya policies and procedures while ensuring person-centered principles are utilized in transitional care planning activities.
• Consult with care managers, care management supervisors, ATCM RN Manager, medical team leaders, and other colleagues as needed to support effective and appropriate member care.
• Address barriers to care for members through convening key providers and others to address needs of the individual and escalate for clinical consultation when necessary.
• Identify and communicate gaps in care related to services and intervenes to ensure that the individuals and specialty populations receive appropriate care.
• Notify and update assigned providers and provide support if provider does not engage or follow up appropriately.
• In cooperation with Hospital Emergency Department or Inpatient physical health discharge planning teams, participate in developing transition plans, educating staff and members regarding network services and supports with consideration of medical necessity, funding eligibility, and appropriateness of recommendations relative to person-centered plan, recovery principles, and known best/appropriate practice.
• Conduct clinical hand-off to community-based CC or CM post discharge.
• Document contacts, completed activities, assessments, and other relevant information within the administrative health record.
• Participate in the development and implementation of best practice complex care strategies as identified by Vaya Health.
• Utilize data feeds and alerts to ensure prompt, efficient coordination and support.

• Associate Degree in Nursing required. Bachelor's Degree in Nursing, Healthcare, or Human Services preferred.
• Two (2) or more years of experience working directly with individuals with physical health, behavioral health, IDD, or TBI needs.
• Experience in Medicaid Managed Care preferred.
• An active and unencumbered RN license. Must be licensed as a registered nurse in North Carolina.

• Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading.
• Physical activity in this position includes crouching, reaching, walking, talking, hearing, and repetitive motion of hands, wrists, and fingers.
• Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.
• Mental concentration is required in all aspects of work.
• Ability to drive and sit for extended periods of time (including in rural areas).

This position is required to reside in North Carolina or within 40 miles of the North Carolina border.