Outpatient Transitional Care Manager, RN Required (Full Time)

A Benefis Transitional Care Manager is responsible for working with patients and their families to assure a smooth transition following discharge from the hospital. The care manager encompasses all care needs of the patient and

remains point of contact for patient/family/legal representative until patient transitions to another service line, OP case manager or patient navigator. Works with all members of the healthcare and multidisciplinary team to assure a collaborative approach is maintained in care and treatment of the patient. Reviews care and treatment for appropriateness against screening and reimbursement criteria for appropriate referral management. Plans and coordinates all necessary care services and needs for the patient. Provides patient/family/legal representative with community and/or care need resources. Organizes and leads necessary care conferences or multidisciplinary care team discussions. Sends any ordered or necessary referrals to the appropriate service line Patient Navigators, Case Manager, or community resource contact for review of appropriateness of services or resources requested. Communicates any changes in the patient's clinical condition that may impact their care plan to the care team and remains point of contact for the patient/family/legal representative. Provides continual monitoring and assessment of patients care plan goals and needs and modifies referrals and resource requests, as necessary.

NON-EXEMPT

Establishes contact with patients immediately following discharge from the hospital to assure that the patient and care partners understand all discharge instructions, receive all test results, and assists in the next step of the care plan.

Demonstrates effective and efficient clinical triaging skills.

Must have thorough knowledge of clinical nursing skills.

Needs to have the ability to complete head to toe assessment for clinical needs.

Serves as patient advocate to ensure continuity of care by following patients receiving services across various care settings; inpatient, outpatient, emergency, home health, etc.

Assists the health care team in developing comprehensive care plans and assesses effectiveness of care plans.

Documents and maintains chart in EHR system per documentation guidelines.

Maintains working knowledge of Center for Medicare and Medicaid services (CMS) administrative rules and regulations and is able to assist in the application and implementation of these regulatory pieces.

Understanding of national healthcare regulations and financial impacts and educates multidisciplinary team members and patient/family.

Supports continuous quality improvement, state and federal regulations, and health information fundamentals in pursuit of improved patient outcomes.

Competent in the use of remote patient monitoring (RPM) software and equipment. Able to provide education to patients and care givers in the use and completion of care pathways.

Ability to implement and revise patients plan of care as indicated by the provider and or care team in regard to patient response to treatment and/or medical workup.

Responsible for communication and hand offs to next level of care to ensure smooth transitions.

Places or submits referrals to appropriate navigator and collaborates to ensure coordinating patient transition/discharge to designated facilities or community care services.

Demonstrates competency in the referral of individualized care needs of patients to the appropriate care service based on age, developmental needs, payor source, and necessary criteria.

Actively participates in case review meetings by providing valuable and relevant updates on patient status and next steps for the patient's continuum of care.

Ability to identify appropriate level of care for patients to: Skilled Nursing, Home Care, Transitional Care, Rehab, Hospice, Palliative Care, and/or private duty.

Perform chart reviews of documentation and information on the patient assessments, interview staff/Provider, and patient/family, to make thorough and appropriate Navigator or community referrals.

Perform other job-related duties and assigned tasks as requested; which may include: cross training and/or other job functions as temporary work loads as volumes require.

Contributes to team effort by accomplishing safe and efficient processes to improve patient outcomes.

Provides clinical education and support to patient and family around the determined medical processes, procedures, treatment, medication, and management of health and wellness.

Assesses complex psychological/social situations or resource needs.

Assists clinical and support staff to make patient follow-up appointments as required.

Provides patient education/documents including accurate medication lists.

Manages and operates equipment safely.

Demonstrates an ability to be flexible, organized and function under stressful situations.

Demonstrates the ability to deal with pressure to meet deadlines, to be accurate, and to handle constantly changing situations.

Professional Requirements:

Adheres to dress code.

Completes annual educational requirements.

Maintains regulatory requirements.

Wears identification while on duty.

Maintains confidentiality at all times.

Attends department staff meetings as required within the department.

Reports to work on time and as scheduled; completes work in designated time.

Represents the organization in a positive and professional manner.

Actively participates in performance improvement and continuous quality improvement (CQI) activities.

Coordinates efforts in meeting regulatory compliance, federal, state and local regulations and standards.

Communicates and complies with the Benefis Health System Mission, Vision and Values as well as the focus statement of the department.

Complies with Benefis Health System Organization Policies and Procedures.

Complies with Health and Safety Standards and Guidelines.