Transformational Care Manager (RN)

Nursing Charlotte, North Carolina


Position Summary

The Transformational Care Manager provides intensive short-term transitional care to individuals with both physical and behavioral health conditions who frequently use the hospital for their care. This transitional care includes:

  • Medication reconciliation
  • Provides disease management and education
  • Discuss ED/hospitalization encounters with patient to improve outcomes

JOB DUTIES

  • Care Managers work in concert with the Primary Care Provider (PCP) and the community to coordinate a full continuum of health care services considering the patient’s unique social and cultural dynamics
  • Assess patients for conditions and concerns that are able to be addressed through community care management
  • Act as a liaison between the PCP, local Health Department (HD), Department of Social Services (DSS), local hospitals, and other community agencies by identifying, arranging, and coordinating physical and/or behavioral health care services in concert with the PCP
  • Collaborate with network providers in assuring appropriate client management
  • Build and maintain relationships with community service providers through collaboration, networking and educating at community functions
  • Assist patients in addressing concerns as needed through referral for assessment, counseling and communication with healthcare team
  • Maintain appropriate client documentation in the EHR
  • Develop and implement individualized care management plans for identified clients
  • Provide direct follow-up and outreach services via face to face encounter (home visit, provider office visit, or community encounter), phone or mail
  • Educate clients and families on the importance of medical care management and the proper method to access care within the medical home environment
  • Educate recipients about disease states to include medication adherence, prevention and risk factor reduction
  • Ensure follow-up with hospital discharge instructions for high risk, high acuity, high cost recipients; ensure continuity of care
  • Act as a liaison to providers to ensure the use of Evidence Based Practices
  • Assist providers with coordination of services for high risk, high acuity, high cost recipients by implementing Evidence Based Practices
  • Coordinate, develop and provide health care education programs and trainings
  • Advocate for patients to receive services that will improve their health condition
  • Assess patients’ plans of care for any duplicate or unnecessary services to control costs to payor
  • Audit charts and compile data to support the disease centered initiatives
  • Responsible for maintaining patient and family confidentiality in accordance with HIPAA
  • Other job duties as required

QUALIFICATIONS

  • Degree in Nursing or Social Work preferred
  • Experience in managed care is highly preferred
  • Must possess a valid driver’s license
  • Personal vehicle is required for travel between work sites