Care Transition Manager
4 days ago
Job Title: Care Transition Manager
Location: Orlando, FL
The Care Transition Manager is responsible for facilitating patient care by coordinating and integrating health and care management functions to achieve a common goal. They work closely with primary care physicians, specialists, psychologists, and social workers to optimize patients' health and well-being, developing and implementing action plans to effectively treat patients.
*Estimated Salary: $60,000 - $80,000 per year*
Key Responsibilities:
- Conduct assessments to identify individual needs and develop a specific care management plan to address objectives and goals identified during assessment(s) for patients enrolled in Care/Disease Management.
- Evaluate Fall Risk, PHQ-9, Health literacy, and risk of unplanned admission.
- Coordinate pre-admission discharge and schedule admission.
- Assist with identifying high-risk populations (i.e., high utilizers, multiple co-morbidities, polypharmacy, non-compliance, at risk for readmission, oxygen dependent, bed and wheelchair bound, etc...)
- Monitor Homebound population and assist with home lab and home visit coordination.
- Assist and coordinate care regarding medical urgencies, not limited to assisting with IVs, wound care, medication administration, etc.
- Will communicate with patient's provider, health plan care manager, and pharmacy team member as needed to assist in coordination of care.
- Educate the patient about the Hotline (Urgency Team), health plan benefits, CCMC services, and community resources.
- Assess the patient for physical functional limitations, poor social support system, and behavioral health needs.
- Assist in problem-solving with providers, utilization or service issues, prior authorization requests, and long-term care applications.
- Ensure patient knowledge of medication compliance and reduce the risk of polypharmacy by providing education and support to help them better understand how to use their medication effectively.
- Implement activities to promote cost savings, such as:
- Potentially prevent admissions by coordinating outpatient care
- Reduce readmissions (Target 10%)
- Improve Generic Dispensing Rate
- Assist patients with coordinating care pertaining to HEDIS/Preventive health screenings. (Target 5 Stars in all Part C and Part D measures, 4 stars in Readmissions)
Required Qualifications:
- Associate degree in nursing required.
- Active Registered Nurse license in Florida.
- Two years of acute clinical experience required.
- Two years of care or case management experience in hospital, health plan, or clinic setting required.
- Proficient computer skills, including experience with Microsoft Excel, Word, and Outlook.
- Strong written and verbal communication skills.
- Excellent clinical assessment and analytical skills.
- Bilingual in English and Spanish preferred.
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