Transitional Care Case Manager

Department/unit

Care Management/Social Work

Work shift

Day (United States of America)

Salary range

$94,957.00 - $147,183.00

Under the guidance of the Case Management Manager and the Transitional Care Clinic Medical Director, the Transitional Care Case Manager (TCCM) facilitates and coordinates appropriate referrals to the TCC. The TCCM assists with managing the referral process, data collection, and ongoing coordination of patient care in the clinic. The TCCM further coordinates post-discharge contacts with indicated patients outside the clinic structure for readmission avoidance. The TCCM works with both internal and external stakeholders to achieve positive outcomes for assigned patients.

Essential Duties and Responsibilities

Collaborates with internal providers, CM/SW teams and nursing to review TCC referrals. Evaluates patient eligibility against TCC accepting criteria. Acts as liaison between inpatient teams, the TCC, and patients and families throughout the referral period to coordinate first post-discharge appointments.

Establishes TCC appointments and ensures patient/caregiver agreement with timing and location. Works with patient/caregiver to secure transportation if needed. Ensures appointment information is available on the AVS.

Completes post discharge transitional care call with in 72 hours. Completes necessary documentation in the EHR. Coordinates with internal and external resources any needs or concerns identified during post-discharge contacts with patient/caregiver.

Documents any updates to care plan in the EHR. Collaborates with TCC Medical Director to complete and aggregate any date related to TCC patients, referrals, and ongoing care plans. This would include anything required for the VBE or grant funds.

Collaborates in presenting ongoing data to internal and external stakeholders when indicated. Remains in communication with TCC provider(s) to assist with any clinical intervention or patient/caregiver education. Implements interventions focused on readmission and ED diversion.

Works with TCC team to ensure hand-off to established or new primary care practice. Acts as point of contact for CDPHP post-discharge for TCC and other identified cases. Participates in clinical performance improvement activities focused on the goals of the TCC and VBE programs.

Expands to non-TCC patients for transition of care tasks based on caseload and as designated by the CM leadership and VBE leadership. Adheres to departmental and hospital regulatory requirements specific to CM role. Works with TCC team to monitor regulatory compliance in the clinic setting.

Documents in the EHR per departmental and hospital standards for discharge planning and any post acute discharge interventions. Qualifications RN - Registered Nurse - State Licensure and/or Compact State Licensure Upon Hire - required Bachelor's Degree preferred 4-6 years or work experience, min of 3 years in direct care nursing and or case management Recent experience in case management, utilization management and/or discharge planning/home care in a high volume, acute care hospital - preferred Demonstrates effective communication, facilitation, and organizational skills. Assertive and creative in problem solving, critical thinking skills, systems planning and patient care management.

Highly proficient interpersonal, communication, organizational and planning skills required. Ability to work autonomously while collaborating with both inpatient and outpatient teams. Self-directed with the ability to adapt in a changing environment.

Basic knowledge of computer systems with skills applicable to utilization review process. Physical Demands Standing - Constantly Walking - Constantly Sitting - Rarely Lifting - Frequently Carrying - Frequently Pushing - Occasionally Pulling - Occasionally Climbing - Occasionally Balancing - Occasionally Stooping - Frequently Kneeling - Frequently Crouching - Frequently Crawling - Occasionally Reaching - Frequently Handling - Frequently Grasping - Frequently Feeling - Constantly Talking - Constantly Hearing - Constantly Repetitive Motions - Constantly Eye/Hand/Foot Coordination - Constantly Thank you for your interest in Albany Medical Center! Thank you for your interest in Albany Med Health System!

Albany Med Health System is an equal opportunity employer. This role may require access to information considered sensitive to Albany Med Health System, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that: Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties.

Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Health System policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.