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Transitional Care Case Manager will function as the central point of contact for a short term transitional care program targeted at inpatient members at a high risk for readmission based on selected diagnoses . This program includes hospital, rehab and skilled nursing facility patient visits as well as home visits and telephonic follow up. Responsible for implementing and coordinating transitional care case management activities for selected plan members. Uses computer-based systems to review medical experience of the member and document all interactions. Schedules member visits telephonically and/or in their home to assist the member to take control of their personal health through utilizing coaching techniques. The Transitional Care Case Manager will work collaboratively with members of the interdisciplinary team such as the attending physician, specialists and other ancillary providers. Will also work closely with plan pharmacists to determine any medication adherence or reconciliation concerns that could adversely affect the member's recovery from an inpatient admission. The program goals include reduction of readmissions, improved physician follow up and increase in member knowledge of their condition and medications.

 

 

-- Registered nurse with current state license

--Certification in Case Management (CCM) required or ability to obtain certification within one year of employment.

--Experience in case management  with strong skills and knowledge of discharge planning, community resources and medical management.

--Experience working with geriatric patient populations

--Experience with using computer systems will be part of the clinical activities.

--Regular local travel may be required.

--Excellent communication skills with coaching techniques is required.

  

- Responsible for the short term management of members identified for the transitional care program by program and condition. 

- Responsible for the proactive management of chronically ill members with the objective of improving quality outcomes and decreasing costs.

- Responsible for the early identification and assessment of members for admittance to a short term chronic care management program.

- Applies case management concepts, principles, and strategies in the development of an individualized case plan that addresses the member's/injured employee's broad spectrum of needs. The case planning process includes the following actions: assessment, goal setting, establishing interventions related to goals, monitoring success of the interventions, evaluating the success of the overall case plan, and reporting outcomes.

- Interviews members telephonically, in their home, physician office or in other facilities to provide initial and ongoing case management services.

- Conducts regular discussions and updates with the plan pharmacists and health plan Medical Directors, health services staff. regarding the status of a particular member.

- Serves as the member advocate to ensure they receive all necessary care allowed under their benefit plan. Develops knowledge of community resources and alternate funding arrangements available to the member when services are not available under their benefits program.

- Develops new programs as appropriate to reduce admissions for acute and chronic members and assist with decreasing their lengths of stay.

- Develops relationships with hospital social workers and community resources to assure appropriate management of catastrophic and chronically ill members.

- Develops an understanding of healthcare reimbursement methods that promotes the provision of cost effective healthcare and the preservation of the member benefits.

- Assists in the identification and reporting of potential quality improvement issues. Responsible for assuring these issues are reported to the Quality Improvement Department.

- Collaborate with plan and corporate case managers and social workers as well as plan concurrent review nurses to promptly identify potential cases and refer cases on at the end of the program.

- May serve as liaison and key resource for Appeals Coordinators for cases involving utilization management, case management, and general medical issues.

- May be responsible for handling sensitive appeal cases that involve complex medical issues assuring all regulatory requirements are met. Works closely with senior management and the Legal Department on these cases.

- Maintains confidentiality of member's information in accordance with HIPAA regulations.

- Performs other duties as required.