Transitional Care Manager

Freedmen's Health; Washington (District of Columbia); On-site; USD 75,000 - 95,000; Full time

Job summary

Freedmen's Health in Washington, DC seeks a Transitional Care Manager to guide Hospital Coordinators and apply expertise in chronic care management. The role emphasizes adherence to timelines for initial and follow-up services and collaboration with the Director of Operations to ensure seamless patient transitions from inpatient to community settings.

The ideal candidate has experience with chronic diseases, strong communication skills, and the ability to develop and monitor care plans, using an

Qualifications

• Knowledge of chronic disease states including CKD, diabetes, COPD and CHF.
• Strong communication, multitasking and time management skills.
• Excellent customer service and interpersonal abilities.
• Experience with an electronic health record (EHR) and learning new systems.

Responsibilities

• Establishes relationships and rapport with hospital staff, discharge planners and others involved in patient transition.
• Oversees transitional care services for patients with medical and/or psychosocial needs.
• Routinely reviews patient status with the Hospital Coordination team and addresses issues in care coordination.
• Develops an initial checklist of key issues related to patient care and tracks completion of care elements.
• Coordinates hand-offs to the Care Management team and escalates unresolved issues when needed.
• Engages in problem solving and informs leadership on actions and current patient status.
• Meets with the Director of Operations to review patient status and ensure issues are resolved.

Skills

Chronic disease management

Strong communication & time management

Patient-centered care

EHR proficiency

Education

Four-year degree in healthcare-related field

Job description

SUMMARY OF DUTIES:

The Transitional Care Manager is responsible for providing management oversight and guidance to all Hospital Coordinators under his/her purview. To do so requires a comprehensive knowledge of chronic care management to include a working knowledge of chronic diseases such as chronic kidney disease, diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, behavioral health, and substance abuse disorders. The Transitional Care Manager is expected to be a subject matter expert in all aspects of the transitional care model (TCM). This includes adherence to identified timelines for initial and follow-up appointments and services. S/he works in collaboration and partnership with individual Hospital Coordinators, and the Director of Operations (DO) to affect seamless patient transition from inpatient status to the community. S/he is responsible for ensuring that Hospital Coordinators are accountable for assisting to develop, implement, and evaluate comprehensive transitional care interventions/plans and to document all items and issues required to intake, collaboratively plan, and implement comprehensive patient care.

PRIMARY RESPONSIBILITIES:

• Fulfills Freedmen’s mission to enhance patient’s lives through quality healthcare to those in need while providing appropriate physical, mental, and emotional care for the whole person.
• Establishes relationships and maintains a professional rapport with key hospital staff to include hospital liaisons, discharge planners, and others involved in the transition of patients from an inpatient setting into the community.
• Oversees the provision of transitional assistance and services for patients with medical and/or psychosocial problems who have had an emergency room visit, inpatient stay and/or skilled care inpatient admission.
• Routinely meets with the Hospital Coordination team to review patient status of care, and works with members of the team, individually or collectively, to address issues with patient coordination and transition.
• Develops an initial checklist of key issues related to patient care and uses this list to track status of completion of key elements of services and care.
• Routinely meets with the Care Management Supervisor to ensure seamless hand-off of patients being transitioned to the Care Management team and work collaboratively to mitigate any issues that have potential to delay provision of services and impact patient care.
• If/when necessary, elevates those hard to resolve issues to the next level of supervision, the Director of Operations.
• Engages in initial problem solving when confronted with issues with patient transition and ensures issues are worked to the greatest extent possible and then ensures leadership is informed on steps taken and current status of patients.
• Routinely meets with the Director of Operations to review and report the individual patient status, to seek guidance on the most appropriate solutions, and to ensure previously raised issues are resolved or being addressed.
• Ensures/provides training and counseling to all Hospital Coordinators on tools, templates, and databases required to accomplish their daily activities and document the status of these in the Hospital Coordinators’ personnel file.
• Work with the Director of Operations and the Executive staff to identify and operationalize appropriate key performance indicators and metrics to be used to assess care coordination productivity and if issues arise, to work to develop a solution to bring metrics into conformity.

EDUCATION:

• A four-year degree in medically related fields of study, social work or other healthcare-related fields of study is preferred but may be substituted with a combination of education and relevant work experience.

EXPERIENCE:

• Minimum of 1-3 year work experience in a healthcare setting involving patients with complex chronic disease conditions preferred.

SKILLS:

• Strong working knowledge of chronic disease states including chronic kidney disease, diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, as well as behavioral health, and substance abuse and basic medical management of these states.
• Must be highly motivated, result-oriented with strong skills in presenting, communicating, multi-tasking and time management skills
• Strong organizational and interpersonal skills
• Excellent customer service skills demonstrated by positive feedback from patients/team.
• Ability to identify problems and recommend solutions
• Ability to read, write and communicate effectively orally and in writing
• Basic computer skills including previous work with an electronic health record (EHR) and ability to learn new systems required to support coordination of care

ENVIRONMENTAL/ WORKING CONDITIONS:

• Transitional Care Manager will be required to physically be on-site as required.

PHYSICAL/ MENTAL DEMANDS:

• Able to manage difficult or emotional patient service situations and respond to requests for patient service and assistance in a timely and appropriate manner.
• Must possess the cognitive/mental ability and patience to employ language and interactive communication skills while engaging with challenging patients suffering from physical, mental, and substance use disorders.

This description is intended to provide only basic guidelines for meeting job requirements. Responsibilities, knowledge, skills, abilities and working conditions may change as needs evolve.