Transitional Care Clinical Manager - Aspen Trace en Cardon Associates
Cardon Associates · Greenwood, Estados Unidos De América · Hybrid
- Professional
- Oficina en Greenwood
SUMMARY: The Transitional Care Clinical Manager plays a vital role in supporting residents as they move across the continuum of care. This is primarily a remote role, while maintaining close communication with residents, families, and providers. Occasional in-person meetings will be required for team collaboration, training, or resident care needs. The Transitional Care Clinical Manager serves as a central connection point between residents, families, community staff, and external providers, ensuring smooth care transitions, clear communication, and strong clinical follow-up.
EDUCATION, QUALIFICATIONS, CREDENTIALS:
* Licensed Nurse (RN or LPN) or other clinical background preferred.
* Experience in skilled nursing, home health, hospice, or transitional care strongly preferred.
* Strong organizational, communication, and people skills, with ability to build rapport both in-person and remotely.
* Proficiency in healthcare technology platforms (Olio, Watershed, or similar).
* Ability to work independently and collaboratively across multiple teams and organizations.
* Licensed Nurse (RN or LPN) or other clinical background preferred.
* Experience in skilled nursing, home health, hospice, or transitional care strongly preferred.
* Strong organizational, communication, and people skills, with ability to build rapport both in-person and remotely.
* Proficiency in healthcare technology platforms (Olio, Watershed, or similar).
* Ability to work independently and collaboratively across multiple teams and organizations.
RESPONSIBLE TO: Director of Clinical Coordination
ESSENTIAL FUNCTIONS: No person shall work under the influence of alcohol, intoxicants, or illegal drugs; or when the person is using medications to the extent that the use adversely affects the performance of his or her duties or the health or safety of any resident.
It is everyone's responsibility to demonstrate high ethical standards and a commitment to compliance with all laws applicable to licensed and certified health care communities.
The Transitional Care Clinical Manager must be able to perform each essential function effectively to be successful in this position.
* Care Continuum Oversight: Manage residents transitioning through the post-acute continuum of care, ensuring safe, timely, and coordinated transitions between the skilled nursing facility (SNF), home health, and hospice settings.
* Technology Utilization: Monitor and track resident progress using software platforms such as Olio and Watershed for timely communication and documentation.
* Collaboration with Home Health & Hospice: Communicate directly with home health and hospice agencies regarding resident condition updates, needs, and care coordination. Attend and coordinate regular in person meetings with companies and providers for data and outcome review for quality improvement initiatives.
* Collaboration with Individual Community Staff: Ability to build relationships and strong collaboration with community staff to ensure safe transitions of care.
* Transitional Care Management (TCM): Conduct post-discharge follow-up calls to residents in the home setting to review medications, identify needs, and connect patients with providers and community-based wrap-around services.
* Medication Reconciliation: Complete thorough medication reconciliations with residents after discharge to ensure accuracy, safety, and compliance, while identifying potential gaps in care.
* Readmission Prevention: Identify barriers or risks for readmission early and collaborate with providers, families, and teams to create proactive care plans.
* Re-admission Coordination: Partner with facility staff and liaison teams when residents require return to the SNF setting, ensuring proactive planning and smooth transitions.
* Remote Relationship Building: Build and maintain strong connections with residents, families, and providers through phone and virtual communication, fostering trust and engagement beyond in-person interactions.
* Team Collaboration: Participate in occasional in-person meetings, training, or facility visits as needed to support alignment and resident care.
* Compliance & Documentation: Ensure all communications and transitions of care are documented accurately and in compliance with regulatory and organizational standards.
* Soft Skills: Ability to influence without direct authority (since much of the role requires collaboration with external providers and internal staff).
It is everyone's responsibility to demonstrate high ethical standards and a commitment to compliance with all laws applicable to licensed and certified health care communities.
The Transitional Care Clinical Manager must be able to perform each essential function effectively to be successful in this position.
* Care Continuum Oversight: Manage residents transitioning through the post-acute continuum of care, ensuring safe, timely, and coordinated transitions between the skilled nursing facility (SNF), home health, and hospice settings.
* Technology Utilization: Monitor and track resident progress using software platforms such as Olio and Watershed for timely communication and documentation.
* Collaboration with Home Health & Hospice: Communicate directly with home health and hospice agencies regarding resident condition updates, needs, and care coordination. Attend and coordinate regular in person meetings with companies and providers for data and outcome review for quality improvement initiatives.
* Collaboration with Individual Community Staff: Ability to build relationships and strong collaboration with community staff to ensure safe transitions of care.
* Transitional Care Management (TCM): Conduct post-discharge follow-up calls to residents in the home setting to review medications, identify needs, and connect patients with providers and community-based wrap-around services.
* Medication Reconciliation: Complete thorough medication reconciliations with residents after discharge to ensure accuracy, safety, and compliance, while identifying potential gaps in care.
* Readmission Prevention: Identify barriers or risks for readmission early and collaborate with providers, families, and teams to create proactive care plans.
* Re-admission Coordination: Partner with facility staff and liaison teams when residents require return to the SNF setting, ensuring proactive planning and smooth transitions.
* Remote Relationship Building: Build and maintain strong connections with residents, families, and providers through phone and virtual communication, fostering trust and engagement beyond in-person interactions.
* Team Collaboration: Participate in occasional in-person meetings, training, or facility visits as needed to support alignment and resident care.
* Compliance & Documentation: Ensure all communications and transitions of care are documented accurately and in compliance with regulatory and organizational standards.
* Soft Skills: Ability to influence without direct authority (since much of the role requires collaboration with external providers and internal staff).
