Discharge & Care Transitions Nurse Manager

AbsoluteCARE Medical Center & Pharmacy; Pittsburgh (Allegheny County); Hybrid; USD 70.000 - 110.000; Vollzeit

Zusammenfassung

AbsoluteCare Medical Center & Pharmacy seeks a Transitional Care Manager to join the ICCT, coordinating discharge planning and post-discharge care for patients in the community and inpatient settings.

The TCM will develop person-centered care plans, ensure timely follow-up with primary care and specialists, coordinate home health and social supports, and monitor outcomes like readmissions and follow-up completion. Travel locally as needed.

Qualifikationen

• In-depth experience planning patient discharge and transitions.
• Experience coordinating post-discharge services in community settings.
• Knowledge of NCQA/PCMH/HEDIS a plus.

Aufgaben

• Meet inpatients to develop PCCP for discharge.
• Call members post-discharge to review instructions and schedule follow-up.
• Coordinate hospital follow-up with PCP and specialists.
• Communicate with AbsoluteCare team and providers.
• Maintain PCCP and comply with protocols.

Kenntnisse

Discharge planning

Care coordination

Care transition

Clinical documentation

Interdisciplinary collaboration

Ausbildung

Registered Nurse license

Tools

EMR systems

Microsoft Office

Jobbeschreibung

AbsoluteCare Medical Center & Pharmacy seeks a Transitional Care Manager to join the ICCT, coordinating discharge planning and post-discharge care for patients in the community and inpatient settings.

The TCM will develop person-centered care plans, ensure timely follow-up with primary care and specialists, coordinate home health and social supports, and monitor outcomes like readmissions and follow-up completion. Travel locally as needed.