Transitional Care Manager - RN chez Complete Health Partners, INC

Location: 3500 Blue Lake Drive Birmingham, AL 35243

Travel to local hospital/rehab facilities is required

Schedule: Monday-Friday

Pay Range: $37.98-46.32 per hour, dependent on experience

JOB SUMMARY:

Under direction of the Director or Nurse Manager of Value Based Care, the Inpatient Navigator acts as a liaison between the patient and/or caregiver, the Transitional Care Manager (TCM), community healthcare providers, and external vendors by visiting admitted patients to discuss the hospitalization course, discharge plan, and post discharge needs with the goal of providing the patient with a positive experience that communicates care and support. As the representative of the Primary Care Provider (PCP), the Inpatient Navigator establishes communication with the patient and/or caregiver on behalf of the Care Management Team and PCP, provides follow up appointment information, and reviews the discharge plan with Case Management and/or attending physician to ensure an effective, efficient, and safe discharge will take place. Collecting pertinent information through these interactions and collaborating with the Care Management team ensures continuity of care, facilitates the ability to address Social Determinants of Health and prepares the TCM to arrange support for the patient in the post-acute setting such as transportation, meal delivery, and assistance with other social barriers.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Travel to inpatient facilities to complete rounds on Value Based Care patients.
• Assists in providing concurrent, and retrospective review of patients during the transitional care period which begins on admission to best meet the needs of the patient and promote high-quality, cost-effective care.
• Ensures all pertinent hospital records from hospital electronic medical record (EMR) to Athena for new admissions/discharges. Requests for inpatient and post-acute records from facilities when EMR access is limited or not obtainable.
• Serves as a liaison between the patient, hospital staff, attending, PCP, and TCM RN.
• Works closely with the Part A Medical Director to determine initial and subsequent patient acuity designations and assignments, ensuring that patients are transferred to appropriate care programs as needed.
• Assesses the patient/caregivers needs and works with Case Management/TCM to ensure a safe, effective, and efficient discharge occurs.
• Assists with obtaining DME and coordinating start of care with Home Health Agencies as needed.
• Collaborates with the Patient Advocate, Referral Coordination, and TCM to assist patients with appointment scheduling with the PCP, specialists, and testing facilities.
• Educates the patient on the TCM and Home Visit programs and facilitates reminders for appointments, labs, and outstanding quality improvement measures prior to discharge.
• Interacts with respect and in a professional manner with patients, staff, and external customers.
• Participates in pertinent meetings, workshops, seminars, and related forums as directed.
• Other duties as assigned and directed by the Director or Nurse Manager of Value Based Care.
• Follows HIPAA and OSHA Standards and guidelines.
• Maintains HR compliance and procedures.
• Ensures patient satisfaction by providing excellent service, putting Patients First, Always.