Job Description

This role is a member of the integrated community care team (ICCT), providing in-person discharge planning, care coordination and integrated case management supports for members currently admitted at an inpatient facility. The transitional care manager (TCM) is assigned acute and post-acute facilities in the community. TCMs are assigned to the members at the time of admission and care coordinate for their complex medical, behavioral, and social determinants of health needs. Working in partnership with the inpatient facility and the health plan, the TCM coordinates care in collaboration with AbsoluteCare Medical Director and primary care providers, community primary care providers and specialists and local community resource and service agencies required to meet the member’s individual post discharge needs. TCM effectiveness is measured by value-based care outcomes including admission and readmission rates, length of stay, bed days and hospital follow-up completion rates.

Duties and Responsibilities

• Meet with members during their inpatient admission and develop a person-centered care plan (PCCP) to address their discharge and care transition needs.
• Call members post discharge to review discharge instructions, complete medication reconciliation and ensure scheduling of hospital follow-up visits.
• Coordinate member post discharge plans including hospital follow-up with primary care provider and specialists, home health, durable medical equipment, medications, social and caregiver supports.
• Communicate with AbsoluteCare team and community primary care providers on a regular basis, review assigned member discharge plans and barriers to a safe discharge.
• Manage PCCP and member contact in compliance with all agency requirements, internal protocols, and accreditation standards.
• Provide education with teach back regarding medical, behavioral, and functional health conditions, symptoms, and treatment options.
• Provide evidence-based clinical interventions centered on established person-centered care plan goals using a variety of approaches, e.g., trauma informed care, harm reduction, behavior change modalities, motivational interviewing, teach back methods and problem solving.
• Attend clinical rounds with health plan partners, review PCCPs for discharge, provide recommendations for appropriate level of care and next steps to expedite care transitions.
• Meet established Key Performance Indicators.
• Manage assigned caseload based on visit and contact frequency requirements and utilization data.
• Proactively mitigate/resolve barriers to care to increase adherence to discharge plan and reduce risk of readmission.
• Assist members in accessing and engaging with AbsoluteCare and community services and resources and follow up on member adherence to referrals.
• Actively participate in required meetings.
• Other duties as assigned to meet business needs.
• Maintain the security and privacy of all information that is owned by AbsoluteCare or maintained on behalf of the company’s patients, employees, and business partners.
• Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.
• This description reflects management’s assignment of essential functions, it does not proscribe or restrict the tasks that may be assigned.
• This job description is subject to change at any time.

Minimum Qualifications

• Must be willing and able to travel up to 80% of the time to local area hospitals, skilled nursing facilities and residential treatment facilities to visit members and build relationships with discharge planners and case management staff.
• Licensed RN by the state in which practicing and abide by all laws, regulations, and requirements.
  • Preference given to RN candidates with extensive experience discharge planning, care transition coordination and medical and behavioral case management in the community. Candidate with CCM or CCTM credentials a plus.
• 3+ years of experience in serving the needs of complex populations, including medically complex, trauma history, mental health conditions, substance abuse, and socioeconomic barriers in an office or community-based setting.
  • Preference given to qualified candidate with multiple settings experience (Inpatient, LTPAC, home health, corrections, community programs and/or human service agencies.)
  • Experience with complex government-sponsored populations preferred, e.g., Medicaid, Medicare beneficiaries.
  • Experience with member engagement, transitions of care, clinical care, and/or case management
• Experienced in discharge planning and care coordination for continuity in care transitions, strategies for reducing readmissions and chronic condition management interventions a must.
• Experienced in concurrent review for level of care determinations and taking action to transition to other care settings by expediting prior authorizations, leveraging the power of influence, and advocating on behalf of the member. Familiarity with MCG and ASAM criteria a plus.
• Ability to take a creative and innovative approach to problem-solving to aid patients in overcoming barriers to care transitions.
• Excellent computer skills including Microsoft Office Suite (Outlook, Excel, PowerPoint, Word) and electronic medical record documentation required.
• Excellent written and oral communication skills to interact with members, families, community stakeholders, and interdisciplinary team required.
• Ability to meet accreditation and quality standards including, but not limited to NCQA, PCMH, HEDIS through following defined procedures to assess, intervene and document interactions.
• Ability to work independently and exercise excellent clinical judgement.
• Active unencumbered driver’s license, with automobile insurance, reliable transportation, and ability to work in office and in the community.
• Second language ability is desirable relevant to local population, geography, resources.

Working conditions

This job operates in the community and within a professional office environment. This role requires reliable transportation to commute back and forth between inpatient facilities and office; and routinely uses general office equipment.

Physical requirements

• Ability to communicate clearly and exchange accurate information consistently.
• Ability to remain stationary for long periods of time.
• Repetitious movements.
• Constantly operates computer, keyboard, copy and fax machine, phone, and other general office equipment.

• Ability to occasionally move objects up to 20 lbs.

Direct reports

None.