TOC Nurse Care Manager

Job Overview:

The Transitions of Care (TOC) Care Manager is responsible for working to coordinate discharge and services between hospitals, acute care facilities, and home. The TOC CM will collaborate with admitting facilities to coordinate safe discharge for members. The TOC CM will participate in case conferences, connect members to medical providers and services, and ensure a safe discharge of the member.

Essential Responsibilities:

• Coordinate Hospitalization, Rehabilitation, and Nursing Home admissions, discharges, and tracking
• Case Conference with Care Managers and facility providers and participate in safe discharge planning
• Communication with home care team regarding home care setup and ongoing coverage; ensuring coverage or backup plan implementation if no coverage
• Communication and coordination of member care with facility providers and vendor agencies
• Follow up and respond to identified items requiring attention
• Timely and thorough documentation in members’ charts
• Participates in weekly team meetings
• Other duties as identified as a necessary part of employee’s role

Specific Knowledge, Skills, and Abilities:

• Knowledge of admissions and discharge planning processes
• Knowledge of member assessment procedure.
• Knowledge of clinical review procedures.
• Demonstrates ability to effectively communicate information with professionals and members of all ages and socioeconomic levels.
• Ability to read and interpret documents. Ability to speak effectively with professionals, members and employees of the agency.

Required Education, Experience, and Licenses:

• The appropriate background in health care and/or long-term care

Specific Knowledge, Skills, and Abilities:

• Valid New York State, unrestricted, RN license.
• Bachelor’s Degree (BSN) preferred.
• Excellent communication, written and analytical skills.
• Computer savvy.

Schedule:

• Hybrid schedule (3 days in office & 2 days remote).