(Archived) Transitional Care Manager

Job Summary

Job Description

Minimum Qualifications

Education: Graduate of an accredited school of professional nursing required, BSN preferred or graduate of an accredited masters of social work program (MSW)

Licenses/Certifications:

• Current and valid license to practice as a Registered Nurse (RN) in the State of Texas or current and valid license as a Licensed Master Social Worker (LMSW) or Licensed Clinical Social Worker (LCSW) in the State of Texas required
• Certification in case management (CCM or ACM) or other area related to chronic disease management or population health preferred, such as CCP, CPUR or CCTM

Experience / Knowledge / Skills:

• Three (3) years of relevant clinical experience required, with at least two (2) years of experience in a care coordination and planning role with complex populations
• Experience working in interdisciplinary teams
• Excellent computer skills
• Excellent communication and interpersonal skills
• Demonstrates commitment to the Partners-in-Caring process by integrating our culture in all internal and external customer interactions; delivers on our brand promise of “we advance health” through innovation, accountability, empowerment, collaboration, compassion and results while ensuring One Memorial Hermann.

Principal Accountabilities

• Manages and supports an assigned population with moderate to complex care needs throughout a 90-day episode of care.
• Navigates patients through the care continuum with the goal of preventing readmissions and ensuring that care is provided at the right time, place, person and location.
• Development of a patient-centered, holistic plan of care through the use of disease-specific pathways tailored to eliminate barriers to care and meet treatment plan goals. Collaborates with treatment teams to coordinate safe and efficient discharges to the appropriate preferred network.
• Serves as a key member of the multi-disciplinary team, facilitating referrals to other interdisciplinary team members such as social workers, community health workers, pharmacy, behavioral health and health coaches in order to provide ongoing care coordination.
• Increases continuity of care by building and facilitating effective and collaborative relationships with post-acute providers, physicians, and community resources. Provides Care Management services to assigned patients face-to face and telephonically. Travels to provider offices, patient homes and post-acute settings may occasionally be required.
• Engages and coordinates with the patient and/or patient’s designated family/caregivers to help resolve barriers to care.
• Advocates for patients to receive relevant and appropriate community resources.
• Manages effective transitions in care by facilitating warm hand-offs with the interdisciplinary team, physicians, and partners in the community.
• Promotes and coordinates timely access to appropriate care, including discharge follow up appointments.
• Facilitates effective and efficient utilization of clinical resources.
• Increases comprehension and health literacy through appropriate education that is tailored to the patient’s preferred learning methods.
• Provides education and coaching regarding chronic disease/s, self-management, community resources, etc. to support and empower patients to take a more active role in managing their health, well-being and shared decision-making.
• Coordinates warm hand-off to member’s primary care provider upon successful completion of the program.
• Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.
• Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.
• Other duties as assigned.