Documents assessment in the medical record to support transition of care services as specified by CMS and other program requirementsPrepares and maintains Transitions of Care and Care Management reports and provides periodic updates to network leadersKnowledge and understanding of Post-Acute relationships pertaining to ACO, CMS, and Value Based Entity requirementsTriages patients to determine those appropriate for medical and/or behavioral care managementCreates a care management action plan with the patient/caregiver that includes elements of self-management, as appropriateWhat qualifications you will need:Graduate of an accredited college of nursing requiredCurrent licensure as an RN in the state of residence and/or practice Certified Case Manager, preferredMinimum of 10 years' experience as an RN, including an administrative capacity with responsibility for the overall operation of the business, requiredBenefits MountainStar Healthcare, offers a total rewards package that supports the health, life, career and retirement of our colleagues. The Clinical Care Manager acts as an integral member of the ACO and CIN network by providing direct leadership to the Clinical Care Coordinators, engaging and managing Post-Acute relationships in the markets, coordinating collaboration with the HCA facilities, partners, providers and leadershipServes as a subject matter expert in care transitions, case management and post-acute care.