Transitional Care Manager

Emerus; United States; On-site; USD 85,000 - 100,000; Full time

Job summary

Emerus in the United States seeks a Transitional Care Manager to oversee patient transitions from hospital to home using evidence-based care coordination. You will identify high-risk patients and work with hospital teams to optimize discharge planning and outcomes.

The role requires a nursing degree with RN license or LMSW, plus hospital discharge planning experience and proficiency with MS Office. Flexibility for after-hours work and telehealth assessments is valued.

Qualifications

• Bachelor Degree in Nursing with an RN license, or LMSW.
• One (1) year hospital clinical experience.
• One (1) year hospital discharge planning experience.
• Ability to work off-hours and on call.

Responsibilities

• Holistic patient assessment for discharge planning needs.
• Participate in hospital multidisciplinary daily rounds.
• Identify patient and family education needs to ensure participation in discharge planning.
• Identify patient concerns and gaps in care during discharge.
• Coordinate with Hospitalists and care teams to bridge gaps.

Skills

Holistic patient assessment

Discharge planning

Care coordination

Multidisciplinary teamwork

Communication skills

Telehealth assessments

Time management

Education

Bachelor Degree in Nursing (RN)

LMSW (multi-state)

Tools

Microsoft Office Suite

Job description

About Us

We are Emerus, the leader in small-format hospitals. We partner with respected and like-minded health systems who share our mission: To provide the care patients need, in the neighborhoods they live, by teams they trust. Our growing number of amazing partners includes Allegheny Health Network, Ascension, Baptist Health System, Baylor Scott & White Health, ChristianaCare, Dignity Health St. Rose Dominican, The Hospitals of Providence, INTEGRIS Health, MultiCare and WellSpan. Our innovative hospitals are fully accredited and provide highly individualized care. Emerus’ commitment to patient care extends far beyond the confines of societal norms. We believe that every individual who walks through our doors deserves compassionate, comprehensive care, regardless of their background, identity, or circumstances. We are committed to fostering a work environment focused on teamwork that celebrates diversity, promotes equity and ensures equal access to information, development and opportunity for all of our Healthcare Pros.

Position Overview

The purpose of this position is to manage a patient’s successful transition from hospital to home. The Transitional Care Manager is responsible for practicing in a high-quality, patient-centered, systematic, and evidence-based approach of assessment, diagnosis, planning, implementation and evaluation for all Emerus patients. As a member of the multidisciplinary health team, the Transitional Care Manager identifies high-risk, complex patients for program enrollment and communicates with all entities involved in the care of the patient to promote and maximize high-quality care coordination. The practice of this position has a direct impact on patient outcomes and Hospital performance measure for Medicare and Medicaid compliance.

Essential Job Functions

• Holistic patient assessment for discharge planning needs
• Participate in hospital multidisciplinary daily rounds
• Identify patient and family education needs to ensure adequate participation in discharge planning
• Identify patient concerns regarding discharge, social risk factors and anticipate potential gaps in care
• Manage patient coordination of care across the care continuum
• Utilize research findings in practice, and participate in program development and implementation
• Coordinate with Hospitalists and advance practitioners to bridge care gaps
• Engagement of appropriate agencies or community resources when high-risk patients are identified
• Evaluate and update market Discharge Planning Resource to meet the market’s healthcare disparity needs
• Establish and maintain professional relationships with physicians, nursing, county agencies, community resources, patients and their support system
• Facilitate decisions and communicate effectively regarding transitional care plans
• Maintain regulatory compliance with CMS Conditions of Participation and DNV NIAHO Accreditation Requirements
• Maintain a working knowledge of community resources related to professional scope of practice
• Knowledge of behavioral health systems, neglect and violence authority agencies, and community or financial resources for underserved or vulnerable populations
• Maintain patient health information privacy at all times and abide by company policies
• Functions as a liaison between the interdisciplinary treatment team and community partners
• Perform patient telehealth assessments
• Utilize financial and insurance resources to maximize the healthcare benefit to the patient
• Arrange post-discharge medical and community referrals for patients with health problems requiring further evaluation and/or additional services
• Apply advanced critical thinking and conflict resolution skills

Other Job Functions

• Excellent customer service and presentation skills
• Willingness to be a valued member on a team with an inspiring mission
• Ability to establish and maintain collaborative, effective working relationships
• Ability to communicate professionally and effectively in all platforms and forums
• Attend staff meetings or other company sponsored or mandated meetings as required
• Ability to manage multiple tasks simultaneously
• Demonstrate professional organization skills
• Perform additional duties as assigned
• Ability to work off-hours and on call when required
• Proficiency with Microsoft Office (Excel, Word, PowerPoint, TEAMS, OneDrive, and Outlook), required
• Proficiency in basic computer troubleshooting

Basic Qualifications

• Bachelor Degree in Nursing with a compact Registered Nurse (RN) license, or multistate LMSW, required
• One (1) year hospital clinical experience, required
• One (1) year hospital discharge planning experience, required