JOB SUMMARY:

Under direction of the Primary Care Physician and supervision of the Director of Value Based Care, the RN Transitional Care Manager (TCM) is responsible to provide services for a panel of Traditional Medicare and Medicare Advantage Plan patients with medical and/or psychosocial problems who have had an emergency room visit, elective surgery/procedure and/or skilled care inpatient/rehab admission. The timeframe of Transitional Care Management is from the initial ER and/or inpatient event to their return to independent or assisted living as appropriate for their level of acuity. Transitional Care Management services include non-face-to-face communication with the patient and/or caregiver, hospital case manager, home health agencies, specialist referrals, outside community and health resources and assistance with scheduling the patient's follow up with primary care provider and specialists.

The TCM Nurse is responsible to obtain and review the admission and discharge documentation, medications, pending diagnostic tests and ordered treatments. The TCM Care Manager provides assessments and support for treatment regimen adherence, medication management, interaction with other qualified health care professionals and education of patient and/or caregiver to support and promote the patient's best ability for self-management, activities of daily living and independent living to decrease incidence of hospital utilization. The TCM Care Manager coordinates efforts with the Chronic Care Managers to ensure that each patient's records are accurately updated, including their problems list, diagnoses, health conditions, mediations list and Care Team and bringing additional medical concerns to the primary care provider as needed. The TCM Care Manager assesses appropriate levels of acute care management and timing for a smooth transition to Chronic Care Management.

Knowledge/Skills/Abilities:

• The TCM Care Manager must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required.
• Must demonstrate personal effectiveness and credibility, collaborative skills, communication proficiency and flexibility. Must demonstrate strong decision making and documentation skills.
• Possesses organizational and problem-solving skills: Identifies and resolves problems in a timely manner; gathers, analyzes and communicates information skillfully; develops alternative solutions in an organized manner.
• Knows, understands and works within the scope of his/her practice.
• Able to delegate responsibilities appropriately to staff licensure, education, and experience.
• Able to work independently and in a multidisciplinary team.
• Keeps leadership informed and seeks advise and/or help from management whenever needed.
• Able to manage difficult or emotional customer service situations and responds to requests for customer service and assistance in a timely and appropriate manner.
• Has excellent written and oral communication skills.
• Uses reason and speaks clearly, respectfully and persuasively in positive and negative situations, focusing on resolving conflict.
• Shows respect and sensitivity for cultural diversity, promotes a harassment-free environment and fosters a non-discriminatory climate.
• Keeps commitments; inspires the trust of others; works with integrity and ethically.
• Adapts to changes in the work environment; demonstrates willingness to change approaches or methods as needed to best fit the situation within practice guidelines.

Essential Duties and Responsibilities:

• The TCM Care Manager follows and maintains a panel of high acuity patients for transition of care from inpatient to outpatient settings.
• Is responsible to coordinate and communicate with providers, staff and patient's Care Team members (including specialists, Case Managers and patient's family and/or representative) regarding the patient's specific and appropriate acuity level of care needed, as determined by their chronic conditions, acute care events and social/living needs.
• Ensures that the care patients receive is efficient, thorough, timely and is properly documented to help patients avoid reoccurrences of ER and urgent care visits and/or hospital readmissions.
• Assists in ensuring the best quality of life possible for each patient in their care.
• Works with the Director of Value Based Care, Lead RN, the Quality Improvement Manager and the MSRs to identify specific patient social and preventative care needs.
• Facilitates resolutions when possible with resources throughout an assigned geographic area.
• Provides regular reporting of activities and statistical status of the TCM patients in his/her care to the Director of Value Based Care & Lead RN as directed.
• The TCM Care Manager helps to fill in for other Value Based Care staff as needed.
• Participates in department rotating "on-call" schedule determined by the Director of Value Based Care & Lead RN. Participates in pertinent meetings, workshops, seminars, and related forums as directed.
• Maintains confidentiality and follows HIPAA and OSHA guidelines. Maintains current Registered Nurse License in the State of Florida.
• Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job.
• Duties, responsibilities and activities may change at any time with or without notice.