Care Manager - Care Transitions (RN)

Job Description

Description

Your passion belongs at UNC Health. Join more than 56,000 teammates working together to improve the health and well-being of the communities we serve across North Carolina.

Summary:

The Transitional Care Case Manager (TCCM) is a clinical liaison between health care providers to ensure the continuation of care for the healthcare consumers. These healthcare consumers are of inpatient class that are transitioning from the hospital to the next level of care and have been identified as a high risk for readmissions. The TCCM role is to follow the healthcare consumer for a continuation of up to 30 days (90 days for TKA/THA) after each episode of inpatient care to assist the healthcare consumer in self care management and interventions for care as needed. While using an evidence based care coordination approach, the TCCM will provide services designed to streamline the healthcare consumers plan of care and interrupt patterns of frequent acute hospitalization or emergency department use. Transitional Care Case Management serves as a means for achieving client wellness and autonomy through advocacy, communication, education, identification or service resources and service facilitation.

Responsibilities:

• Identifies high risk admissions and prioritizes patients. Uses comprehensive assessment, planning, implementation, evaluation skills and outcome targeting related to the diagnosis. Assists the healthcare consumer and support system(s) in identifying and securing appropriate services to address needs across the healthcare continuum. Performs follow up telephone calls with the healthcare consumer/support system. Provides education to the healthcare consumer/support system on the disease process when needed. Reviews the home medication list and determine the level of understanding of the medication regimen.

• Reviews the discharge plan with healthcare consumer/support system. Encourages that a follow up visit is scheduled with the primary care physician and assess if the healthcare consumer has transportation to the appointment. Performs interventions after discharge, as needed. If discharged home and meets criteria, offer a transitional home visit for healthcare consumers. Documents activities, events, and information per standards in established software systems in a timely, accurate, and complete manner. Maintains ongoing reports of all open and closed cases.

• Collaborates with the healthcare consumer, support system(s) and others in the conduct of nursing practices. Employs strategies to promote health and a safe environment. Assists the healthcare consumer in self determination by utilizing informed decision making. Treats the healthcare consumer and support system(s) with respect. Uses established policies and processes to handle, discuss, and transmit protected health information in manner consistent with privacy and compliance expectations and policies.

• Monitors high risk complex care patients and collaborate to problem solve issues with complex patients and identify trends. Formulates potential solutions with interdisciplinary care team and continuously monitors cases/follow up on all action items.

PARDEE

Other information:

Hired applicants will be expected to obtain Care Management certification.

Required

• Must be licensed to practice as a Registered Nurse in the state of North Carolina or one of compact states.

• Basic Life Support (BLS) certification.

Preferred

• Bachelors of Science in Nursing (BSN).

• Experience working in a Case Management/Discharge Planning capacity.

01.6015.1504

Job Details

Legal Employer: Pardee - HCHC

Entity: Pardee UNC Health Care

Organization Unit: Acute Care Case Management

Work Type: Full Time

Standard Hours Per Week: 40.00

Work Assignment Type: Onsite

Work Schedule: Day Job

Location of Job: PARDEEHOSP

Exempt From Overtime: Exempt: Yes

Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation.