Transitional Care Manager

** Must be an RN with current license

**Westover Hills Hospital

** 70-80K depending on experience

Manage and lead the Transitional Care Program . Lead the team to ensure coordinated care for patients with complex care needs. Assist with transition from acute care to home or intermediate care. Work with patients to implement discharge instructions, reduce readmission, reconcile medications, and assist the patient to initiate the next level of care by coaching self-management of disease process.  Improve the discharge process and improve patient satisfaction with discharge.

• Interviews and hires new staff members.
• Perform 90 day and annual employee evaluations.
• Performs all payroll duties and functions including approving PTO and scheduling of all staff.
• Makes staff assignments as required.
• Identifies and visits patients who have frequent readmissions while in hospital setting.
• Review all readmissions to the hospital daily, determine cause and identify breakdowns, input data into MIDAS.
• Develop weekly readmission report and discuss all unplanned related readmissions with Multidisciplinary Team and CM Director.
• Identify target diagnoses’ to work toward reducing preventable readmissions.
• Maintain tracking of data to support the success of the program including: Inpatient Hospital Readmission, Rehab Readmissions, Transitional Care Program Data, Remote Patient Monitoring Data, Mileage, Emergency Room and Direct Admit Data.
• Attend Multidisciplinary Rounds daily to identify patients at high risk of readmission.
• Referrals to outside sources to assist in the success of the discharge plan.
• Maintain Bi-Monthly meetings with CHRISTUS Health- Health Informatics regarding RPM process.
• Oversee all daily functions of Remote Patient Monitoring.
• Supervises the maintenance and accuracy of patient care and records.
• Performs chart audits on all patients enrolled into the program.
• Leads Bi-Monthly staff conferences and mandatory in-services.
• Implements and supervises all patient care activities to ensure the delivery of safe, economical, and efficient patient care.
• Oversee Long-Term Care TC Nurse and develop process for patient enrollment and program structure.

QUALIFICATIONS:

• Preferred graduate of accredited ADN or BSN program
• Preferred 2-3 years Medical/Surgical experience as a RN or ICU/ER experience.
• Preferred experience in the field of Care Transitions.
• Must maintain a TX compact license and provide verification.

SKILL REQUIREMENTS:

• Must have computer proficiency for documentation and tracking data.
• Must have the ability to communicate effectively, both verbally and in writing.
• Must have the ability to manage several projects and cases simultaneously.
• Must have knowledge of community resources and cultural competence.
• Must have organizational skills.
• Must have knowledge of the under insured, or uninsured populations within the service area.
• Must have the ability to educate & coach clients on a level beneficial to the client’s needs.