The Transitions Care Manager, as a member of the health care team, collaborates to enhance the delivery of patient care services along the continuum of care. The Transitions Care Manager meets patient's needs efficiently and expeditiously by continuously improving the patient's experience, helping to ensure the institutional standards of high quality patient care, reducing cost and ensuring reimbursement. Through broad knowledge of clinical care and systems management, the Transitions Care Manager evaluates, predicts, and facilitates transitions of care.
The position requires a high degree of flexibility, independence, and willingness to participate in multiple activities and provide support to all members of the project team. The position must have strong communication skills and the ability to communicate comfortably with patients and their caregivers, members of the interdisciplinary team, physicians and other practice staff, and program and administrative staff. The Transitions Care Manager collaborates with all members of the interdisciplinary team to assess ACO patients referred to and admitted to SNF; to assure safe and effective transitions to and from the SNF; to monitor and provide clinical guidance throughout the SNF stay and for a defined post-SNF discharge period.
Evaluates ACO patients referred for admission to skilled nursing facilities for level of care (direct from home, PCPs office, or from hospital); utilizes and applies level of care and SNF length of stay decision-support software at time of transition, during the SNF stay, and at time of SNF discharge
Collaborates with partnering skilled nursing facilities to safely and effectively transition patients in to the facility and at time of discharge from the facility
Facilitates coordination of care for ACO patients in skilled nursing facilities during the stay and at discharge; for iCMP patients, in collaboration with the iCMP Care Managers
Establishes the anticipated length of stay at time of transition and monitors and provides length of stay guidance to the SNF facility.
Ensures the timely implementation of the plan of care at the SNF and appropriate patient progression to discharge, navigating any barriers to care. This is accomplished through SNF rounding, telerounding or teletracking.
Ensures that the plan of care and services provided at the SNF are patient focused and friendly, high quality, efficient, and cost effective. Advocates for the patient and family, as indicated.
Ensures that all elements critical to the plan and trajectory of care have been communicated to the patient/family, PCP, and all other members of the interdisciplinary team.
Acts as the liaison by consulting and collaborating with members of the health care team including Inpatient case managers, Practice based staff, and other provided to promote continuity of care as patient move through the continuum.
Documents assessments, planning, and interventions in the electronic medical record
Performs other duties as assigned.
Mass RN License
Bachelor's degree required, Case Manager certification preferred
Experience in a variety of health care settings is preferred.
Strong assessment and problem solving skills.
Strong interpersonal skills.
Ability to work independently with minimal supervision.
Goal oriented and accountable.
Demonstrated organizational skills.
Demonstrated ability to work in a complex setting.
Ability to work in an interdisciplinary team based environment.
Strong oral and written communication skills.
Experience with electronic medical records preferred