Patient-Centered Care Transitions Manager

100 Stormont-Vail HealthCare, Inc.; Topeka (KS); Sur place; USD 68 000 - 86 000; Plein temps

Résumé du poste

Stormont Vail HealthCare is seeking a Care Manager to coordinate patient care across the health system, collaborating with primary care, specialists, and hospitals to ensure safe, efficient transitions and high-value outcomes.

The role emphasizes evidence-based practice, patient-centric planning, and performance improvement within a patient-facing, remote-enabled model. NIH? (If any) No NIH here.

Qualifications

• BSN required and RN license in Kansas.
• 2 years nursing experience in acute or ambulatory settings preferred for care management.
• Case/care management experience preferred but not mandatory.
• BLS certification required within 90 days of hire.

Responsabilités

• Actively participates in clinic redesign and PCMH expansion.
• Collaborates with primary care, social work, and care team for optimal coordination.
• Establishes collaborative relationships with practices engaged in improvement activities.
• Identifies high-risk patients and initiates proactive communication.
• Aggregates data from multiple systems to form a complete performance picture.
• Implements data-driven interventions and monitors outcomes.
• Oversees patient care transitions and discharge planning with care teams.
• Guides patients through the health system and provides disease-specific education.
• Documents and tracks data related to targeted populations for process improvement.
• Facilitates communication with providers and families, ensuring timely follow-up.

Connaissances

Care coordination

Interdisciplinary teamwork

Critical thinking

Communication

Problem solving

Organization

Formation

BSN

Outils

Electronic Health Records

Description du poste

Stormont Vail HealthCare is seeking a Care Manager to coordinate patient care across the health system, collaborating with primary care, specialists, and hospitals to ensure safe, efficient transitions and high-value outcomes.

The role emphasizes evidence-based practice, patient-centric planning, and performance improvement within a patient-facing, remote-enabled model. NIH? (If any) No NIH here.