Transitional Care Manager
4 weeks ago
This role is a key member of the integrated community care team, providing in-person discharge planning, care coordination, and integrated case management supports for members currently admitted at an inpatient facility.
The Transitional Care Manager (TCM) is assigned to acute and post-acute facilities in the community, working in partnership with the inpatient facility and the health plan to coordinate care in collaboration with AbsoluteCare Medical Director and primary care providers, community primary care providers, and specialists, as well as local community resource and service agencies required to meet the member's individual post-discharge needs.
Key Responsibilities- Meet with members during their inpatient admission and develop a person-centered care plan (PCCP) to address their discharge and care transition needs.
- Call members post-discharge to review discharge instructions, complete medication reconciliation, and ensure scheduling of hospital follow-up visits.
- Coordinate member post-discharge plans, including hospital follow-up with primary care providers and specialists, home health, durable medical equipment, medications, social, and caregiver supports.
- Communicate with AbsoluteCare team and community primary care providers on a regular basis, reviewing assigned member discharge plans and barriers to a safe discharge.
- Manage PCCP and member contact in compliance with all agency requirements, internal protocols, and accreditation standards.
- Provide education with teach-back regarding medical, behavioral, and functional health conditions, symptoms, and treatment options.
- Provide evidence-based clinical interventions centered on established person-centered care plan goals using a variety of approaches, e.g., trauma-informed care, harm reduction, behavior change modalities, motivational interviewing, teach-back methods, and problem-solving.
- Attend clinical rounds with health plan partners, reviewing PCCPs for discharge, providing recommendations for appropriate level of care, and next steps to expedite care transitions.
- Meet established Key Performance Indicators.
- Manage assigned caseload based on visit and contact frequency requirements and utilization data.
- Proactively mitigate/resolve barriers to care to increase adherence to discharge plan and reduce risk of readmission.
- Assist members in accessing and engaging with AbsoluteCare and community services and resources and follow up on member adherence to referrals.
- Actively participate in required meetings.
- Other duties as assigned to meet business needs.
- Licensed RN by the state in which practicing and abide by all laws, regulations, and requirements.
- Preference given to RN candidates with extensive experience in discharge planning, care transition coordination, and medical and behavioral case management in the community.
- Candidate with CCM or CCTM credentials a plus.
- 3+ years of experience in serving the needs of complex populations, including medically complex, trauma history, mental health conditions, substance abuse, and socioeconomic barriers in an office or community-based setting.
- Preference given to qualified candidates with multiple settings experience (inpatient, LTPAC, home health, corrections, community programs, and/or human service agencies).
- Experience with complex government-sponsored populations preferred, e.g., Medicaid, Medicare beneficiaries.
- Experience with member engagement, transitions of care, clinical care, and/or case management.
- Experienced in discharge planning and care coordination for continuity in care transitions, strategies for reducing readmissions, and chronic condition management interventions a must.
- Experienced in concurrent review for level of care determinations and taking action to transition to other care settings by expediting prior authorizations, leveraging the power of influence, and advocating on behalf of the member.
- Familiarity with MCG and ASAM criteria a plus.
- Ability to take a creative and innovative approach to problem-solving to aid patients in overcoming barriers to care transitions.
- Excellent computer skills, including Microsoft Office Suite (Outlook, Excel, PowerPoint, Word), and electronic medical record documentation required.
- Excellent written and oral communication skills to interact with members, families, community stakeholders, and interdisciplinary teams required.
- Ability to meet accreditation and quality standards, including, but not limited to, NCQA, PCMH, HEDIS, through following defined procedures to assess, intervene, and document interactions.
- Ability to work independently and exercise excellent clinical judgment.
- Active, unencumbered driver's license, with automobile insurance, reliable transportation, and ability to work in office and in the community.
- Second language ability is desirable, relevant to local population, geography, resources.
-
RN Case Manager
3 weeks ago
Akron, Ohio, United States Summa Health System Full timeJob Summary:As a RN Case Manager - Transitional Care Coordinator at Summa Health System, you will play a critical role in facilitating the development, implementation, and evaluation of individualized patient plans. Your expertise will ensure seamless transitions between care settings, promoting optimal clinical outcomes and effective utilization of...
-
Social Worker
3 weeks ago
Akron, Ohio, United States Summa Health System Full timeJob Summary: We are seeking a skilled Social Worker to join our Transitional Care Management team at Summa Health System. As a key member of our team, you will collaborate with ambulatory and inpatient care management teams to assess, plan, implement, coordinate, monitor, and evaluate services for patients with multiple health needs. Your expertise will help...
-
Akron, Ohio, United States Akron Children's Hospital Full timeJob Summary:The Akron Children's Hospital seeks a skilled Clinical Nurse Manager to lead its 7 Surgical and Subspecialty/Transitional Care unit. As a nurse leader, you will be responsible for creating a safe and healthy environment that supports the work of the healthcare team and contributes to patient engagement.Key Responsibilities:Financial management,...
-
LPN - Transitional Care Specialist
4 weeks ago
Akron, Ohio, United States Cleveland Clinic Full timeCleveland Clinic Akron General is seeking a skilled Licensed Practical Nurse (LPN) to join our Transitional Care Unit (TCU) team. As an LPN in this role, you will provide top-quality nursing care to adult and geriatric patients with a variety of diagnoses, including COPD, asthma, pneumonia, diabetes, GI bleed, sepsis, renal failure, cellulitis, DVT,...
-
Nurse Practitioner
3 weeks ago
Akron, Ohio, United States Cleveland Clinic Full timeJob SummaryCleveland Clinic Akron General is seeking a dedicated Registered Nurse to join our Transitional Care Unit (TCU) team. As a Registered Nurse in this role, you will provide direct nursing care to adult and geriatric patients with a variety of diagnoses, including COPD, asthma, pneumonia, diabetes, GI bleed, sepsis, renal failure, cellulitis, DVT,...
-
Renal Care Manager
4 weeks ago
Akron, Ohio, United States Somatus Full timeJob Title: Renal Care ManagerAt Somatus, we're revolutionizing kidney care by empowering patients to take control of their health. As a Renal Care Manager, you'll play a critical role in improving patient outcomes by coordinating care across multiple settings.Responsibilities:Conduct comprehensive assessments to identify patient needs and barriers to...
-
Care Management Coordinator
4 weeks ago
Akron, Ohio, United States Summa Health Full timeCare Management AssistantSumma Health is seeking a highly organized and detail-oriented Care Management Assistant to provide administrative support to our licensed care management team.Key Responsibilities:Provide clerical assistance with care coordination and transition planning effortsSupport efficient movement of patients to post-acute facilities,...
-
Renal Care Manager
3 weeks ago
Akron, Ohio, United States Somatus Full timeEmpowering Patients with Chronic Kidney DiseaseSomatus is a leading value-based kidney care company that is revolutionizing the industry by empowering patients with chronic kidney disease to experience more days out of the hospital and healthier at home.We are seeking a skilled Renal Care Manager to join our team of passionate and tenacious innovators who...
-
Regional Home Manager
4 weeks ago
Akron, Ohio, United States Total Renal Care, Inc. Full timeLead a Team of Healthcare ProfessionalsAs a Regional Home Manager at Total Renal Care, Inc., you will oversee a team of healthcare professionals in an outpatient clinic setting. Your primary responsibility will be to ensure the delivery of high-quality patient care and to drive clinical outcomes.Key Responsibilities:Partner with physicians and surgeons to...
-
Akron, Ohio, United States Akron Children's Hospital Full timeJob Summary:The Nurse Manager is responsible for creating a safe and healthy environment that supports the work of the healthcare team and contributes to patient engagement. This role is influential in creating a professional environment and fostering a culture where interdisciplinary team members contribute to optimal patient outcomes and grow...
-
Regional Home Manager
4 weeks ago
Akron, Ohio, United States Total Renal Care, Inc. Full timeRole SummaryAs a Regional Home Manager at Total Renal Care, Inc., you will be responsible for leading a team of registered nurses and overseeing the operations of home dialysis programs in your region. You will work closely with physicians, surgeons, and other healthcare professionals to ensure high-quality patient care and drive clinical outcomes.Key...
-
Care Management Coordinator
4 weeks ago
Akron, Ohio, United States Summa Health Full timeCare Management CoordinatorJob SummaryThe Care Management Coordinator provides administrative support to the licensed members of the Care Management team. This role involves clerical assistance with care coordination and transition planning efforts, including receiving task triggers to create referrals and transmitting them to post-acute care provider...
-
Nephrology Care Specialist
4 weeks ago
Akron, Ohio, United States Total Renal Care, Inc. Full timeAbout the Role: We are seeking a skilled Nephrology Care Specialist to join our team at Total Renal Care, Inc. As a key member of our interdisciplinary team, you will play a vital role in delivering high-quality care to patients with end-stage renal disease or chronic kidney disease.Responsibilities:Deliver nephrology care through hemodialysis, peritoneal...
-
Registered Nurse
4 weeks ago
Akron, Ohio, United States Cleveland Clinic Full timeJob SummaryCleveland Clinic Akron General is seeking a Registered Nurse (RN) Resident I to join our Transitional Care Unit (TCU) team. As a RN Resident I, you will work alongside experienced nurses to provide high-quality patient care and develop your nursing skills in a dynamic and supportive environment.ResponsibilitiesProvide direct nursing care to adult...
-
Clinical Care Coordinator
4 weeks ago
Akron, Ohio, United States Insight Global Healthcare Full timeJob SummaryInsight Global Healthcare is seeking a skilled In Patient Case Manager to coordinate the care and services of selected member populations. The ideal candidate will have 2+ years of experience working as an RN Case Manager, with a strong background in NICU/Cardiac/Med Surg specialty experience.Key ResponsibilitiesClinically assesses, plans,...
-
Akron, Ohio, United States Akron Children's Hospital Full timeJob Summary:The Clinical Nurse Manager is a key leader at Akron Children's Hospital, responsible for creating a safe and healthy environment that supports the work of the healthcare team and contributes to patient engagement. This influential role fosters a culture where interdisciplinary team members contribute to optimal patient outcomes and grow...
-
Rehabilitation Case Manager
3 weeks ago
Akron, Ohio, United States Edwin Shaw Rehabilitation Hospital Full timeOverviewCleveland Clinic Rehabilitation Hospital, Edwin Shaw, and Select Medical have partnered to provide exceptional care to patients with complex medical needs.The Case Manager plays a vital role in coordinating healthcare decisions, ensuring treatment plans improve quality and outcomes, and promoting cost-effective care.Key responsibilities...
-
Nurse - Home Care Specialist
4 weeks ago
Akron, Ohio, United States Community Behavioral Nursing Services Full timeJob SummaryWe are seeking a skilled and compassionate Nurse to join our team at Community Behavioral Nursing Services. As a Home Care Specialist, you will provide high-quality nursing care to individuals with developmental disabilities in a group home setting.Key Responsibilities:Provide skilled nursing care to assigned patients, including vital sign...
-
Nurse Practitioner
4 weeks ago
Akron, Ohio, United States Summa Health System Full timeJob SummaryAs a Nurse Practitioner in Primary Care, you will utilize your knowledge of nursing principles and evidence-based practice to provide high-quality patient care. Your expertise will be essential in coordinating and delegating care to ensure the best possible outcomes for our patients.Key ResponsibilitiesDeliver comprehensive primary care to...
-
Akron, Ohio, United States Akron Children's Hospital Full timeJob SummaryWe are seeking a highly skilled and compassionate Staff Nurse to join our team at Akron Children's Hospital. As a key member of our surgical and subspecialty care team, you will provide exceptional patient care and support to our patients and families.ResponsibilitiesAssess, plan, implement, and evaluate patient care plans to ensure optimal...
