Transition Care Manager

Role Overview: The Transition Care Manager helps eligible members achieve their best possible health through care management and coordination services. This role collaborates with members, caregivers, and providers to assess needs, develop individualized plans, and establish health goals. The position coordinates high-quality, cost-effective care, serves as the primary point of contact and advocate for program participants, and ensures services comply with health plan requirements, National Committee for Quality Assurance (NCQA) standards, and applicable federal and state regulations.

Work Arrangements:

• Remote – The associate must be in New Hampshire (NH) or bordering states.

Responsibilities:

• Assess members through face-to-face encounters and by telephone to determine care coordination and care management needs for all referred members.
• Completes comprehensive person-centered assessment, inclusive of physical health history, mental health history, social determinants of health, and supportive needs
• Coordinates physical, behavioral health, and social services.
• Provides medication management, including regular medication reconciliation and support of medication adherence.
• Identifies problems/barriers for care coordination and appropriate care management interventions.
• Creates a plan of care to assist members in reducing/resolving problems and or barriers so that members may achieve their optimal level of health.
• Identifies goals and assigns priority with associated time frames for completion. 
• Shares goals with the member and family as appropriate.
• Identifies and implements the appropriate level of intervention based upon the member’s needs and clinical progress.
• Schedules follow-up calls as necessary and makes appropriate referrals. 
• Documents progress towards meeting goals and resolving problems within the Electronic Medical Record (EMR) system.
• Coordinates care and services with the Community Health Navigator, member, caregiver, Primary Care Provider (PCP), and Specialist.
• Meets regularly with designated partners regarding the member's care plan.

 Education & Experience:

• 3 to 5 years of experience with case management and transition of care planning.
• Experience working with individuals with complex needs. 
• Case management experience, preferably within a managed care organization, is desired.
• Proficient with various technologies, including Microsoft Tools and EMR systems.

 Licensure:

• Current and unrestricted Registered Nurse (RN) license.
• Current and unrestricted Licensed Master Social Worker (LMSW) or Licensed Clinical Social Worker (LCSW) license, with experience managing medical complexities.

 Skills & Abilities:

• Demonstrate ability to be self-directed, independent, adaptive, flexible to change, and able to collaborate as a team member in a fast-paced, ever-changing environment.
• Demonstrate awareness, attitude, knowledge, and skills needed to work effectively with a culturally and demographically diverse population.
• Proficiency using MS Office (Word, Excel, Outlook, Teams), internet applications, and electronic medical record and documentation programs.
• Demonstrate strong organizational and time management skills with the ability to promptly prioritize and follow through on multiple items.
• Demonstrate knowledge and experience in assessing members’ situations, developing a care plan, and teaching self-management