transitional care manager

Kaiser Permanente

<div><div><b>Job Summary:</b></div><br>
<br>
<p>Responsible for coordinating care for identified members with complex medical conditions in collaboration with hospital physicians, QRM staff (IPCC, CM, SW, PTSP), practitioners, medical office staff and other providers. The goal is to support and facilitate a smooth transition from the acute care setting or skilled nursing facility to alternative levels of care or home. Collaborates with physicians, telephonic care coordinators, inpatient case management/ social workers, telephonic to create a safe discharge plan for identified complex patients. Key job functions include assessment of identified members, development of a safe discharge plan from acute inpatient, skilled nursing, LTAC and Inpatient Rehab facilities. Coordinates post-acute services and follow- up medical care to ensure continuity of care. The Acute Transitional Case Manager (TCM) will identify and communicate any barriers to discharge plan. Ensures appoints and coordination of post-acute services with vendors.</p><div><b><br>
Essential Responsibilities:</b></div><br>
<br>
<ul><li>Responsible for all transitional case management activities outlined above.</li><li>
Conducts timely reviews and refers Transitional Case Management Program or Complex Case Management within designated timeframe per policy and procedure and evaluates priority for continuity of care case management based on established guidelines.</li><li>
Performs a thorough and objective telephonic assessment of the member including physical, psychosocial, environmental, financial, and health status expectation through the use of hospital records, contact with the member/family or significant others.</li><li>
Develops an individual, mutually established plan of care based on the assessment and utilizing motivational techniques, in conjunction with the KP Hospitalists and other practitioners that identifies specific interventions, objectives and goals with anticipated targeted dates for accomplishment.</li><li>
Attends patient care conferences (rounds) as scheduled with QRM physicians, and Telephonic IPCC work together to discuss clinical course, discharge planning and provide feedback on planned interventions, or barriers to care for member self-management to avoid delays and promote smooth transition.</li><li>
Proactively, implements the plan of care and specific interventions that will lead to the accomplishment of goals as defined. This may entail implementation prior to member discharge.</li><li>
Coordinates the resources necessary to accomplish the goals,and makes recommendations for modifications to the plan of care as necessary.</li><li>
Performs telephonic outreach to identified members within 48 hours post hospital discharge and completes assessment of member status.</li><li>
Coordinates and communicates plan of care to the Primary and/or Specialist Care providers, including follow-up appointment.</li><li>
Makes referral to other KP programs for continued care support.</li><li>
Documents all case management interactions and interventions according to departmental guidelines.</li><li>
Coordinates and participates in complex case management conferences on a regular basis for members involved in the care and updates the plan of care as necessary.</li><li>
Continuously coordinates, monitors, tracks and evaluates all care and services rendered to ensure that quality care is being delivered and in the most appropriate setting.</li><li>
Re-assess and reinforce members self-management skills, including symptom and medication management.</li><li>
Acts as a resource to facility Case Managers and discharge planners.</li><li>
Provides case management updates to practitioners and health care teams.</li><li>
Collaborates with the healthcare team to provide referral information and regarding community resource referrals.</li><li>
Arranges, coordinates and facilitates appointments for the member as necessary.</li><li>
Builds effective working relationships with practitioners and other departments within the health plan.</li><li>
Works in conjunction with disease specific population based care department as appropriate.</li><li>
Consults with Chief of QRM for potential non-approvals, benefit exceptions and other issues as appropriate.</li><li>
Assists in the development of guidelines and protocols.</li><li>
Investigates, identifies and reports problems and inefficiencies in existing systems, and recommends changes when appropriate to the Supervisor.</li><li>
Under the guidance of the Supervisor and in consultation with other QRM staff, participates in the coordination, planning, development, implementation, and maintenance of all QRM policies and procedures.</li><li>
Monitors utilization trends concerning inpatient and outpatient care in the market area, keeping appropriate management informed.</li><li>
Refers cases identified as risk management, peer review or quality issues to Quality and Risk Management.</li><li>
Provides documentation regarding any pertinent patient information or arrangements for inclusion in the members medical record.</li><li>
Works cross-functionally with other departments in striving to meet organizational goals and objectives.</li><li>
Participates in call rotation to support after hours and weekend referrals for quality resource management services.</li><li>
Acts as a team coach for respective areas of responsibility regarding enhanced customer service, quality of work performed and productivity of staff.</li><li>
Knowledgeable and compliant with regional personnel policies and procedures.</li><li>
Knowledgeable and compliant with QRM departmental and unit specific policies and procedures.</li><li>
Participates in annual regional and departmental compliance training.</li><li>
Knowledgeable and compliant with Principles of Responsibility.</li><li>
Develops and maintains an awareness of how to report compliance issues and concerns. Consistently supports compliance and the Principles of Responsibility (Kaiser Permanentes Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state and local laws and regulations, accreditation and licenser requirements (if applicable), and Kaiser Permanentes policies and procedures.</li><li>
Your access to protected health information (PHI) will be limited to the minimum necessary required to effectively perform your job.</li><li>
May perform other duties as assigned.</li><li>
Other duties as assigned.</li></ul><div><br>
<b>Basic Qualifications:</b></div>
<div>Experience</div><br>
<br>
<ul><li>Minimum three (3) years acute hospital discharge planning or prior experience in case management as an RN.</li></ul><div>
Education</div><br>
<br>
<ul><li>High School Diploma or General Education Development (GED) required.</li></ul><div>
License, Certification, Registration</div>
Registered Professional Nurse License (Georgia) OR Licensed Clinical Social Worker (Georgia) OR Licensed Master Social Worker (Georgia)<br>
<ul><li>
</li></ul><br>
<div><b>Additional Requirements:</b></div><ul><li>
Complex Case Management experience.</li><li>
Experience acute patient populations including Medicare members.</li><li>
Functional knowledge of computers.</li><li>
Must be able to travel within the Atlanta metro area</li></ul><div>
<b>Preferred Qualifications:</b></div><br>
<br>
<ul><li>Bachelors Degree in Nursing or four (4) years of experience in a directly related field.</li></ul><br>
PrimaryLocation : Georgia,Atlanta,Regional Office - 9 Piedmont<br>
HoursPerWeek : 40<br>
Shift : Day<br>
Workdays : Mon, Tue, Wed, Thu, Fri<br>
WorkingHoursStart : 08:30 AM<br>
WorkingHoursEnd : 05:00 PM<br>
Job Schedule : Full-time<br>
Job Type : Standard<br>
Employee Status : Regular<br>
Employee Group/Union Affiliation : GUP|UFCW|Local 1996<br>
Job Level : Entry Level<br>
Job Category : QA, UR &amp; Case Management<br>
Department : Regional Office - 9 Piedmont - Rgnl Clinical Innovation - 2808<br>
Travel : No<br>
Kaiser Permanente is an equal opportunity employer committed to fair, respectful, and inclusive workplaces. Applicants will be considered for employment without regard to race, religion, sex, age, national origin, disability, veteran status, or any other protected characteristic or status.</div>

RN QRM Acute Transitional Case Manager

Ensign Affiliate

<div><div><b>OCCUPATIONAL THERAPIST &ndash; FULL TIME - </b><b>OLYMPIA TRANSITIONAL CARE &ndash; OLYMPIA, WA</b></div>
<div><b>This job was posted and verified on 3/19/2026</b></div>
<div></div><div><b>Flexible schedule with work-life balance</b><br>
<b>Call or text Carly Peevers for more information at </b><b>775-741-1406</b><br>
<b>or e-mail cpeevers@EnsignServices.net</b></div>
<div></div><div><div><div><div><div><div><div>Olympia Transitional Care in Olympia, WA, is a post-acute care facility with long-term care, short-term care, and geriatric services provided. We can offer a stable and fun in-house therapy team to work with as well as excellent programs serving our geriatric clientele in their journey to recovery. We are currently seeking a full time Occupational Therapist for our in-house rehab program!</div>
<div></div><div><b>Duties:</b></div>
<div><ul><li>Effectively screens/evaluates patients with cognitive and/or ADL physical functioning disorders and develops appropriate plan of care following all regulatory and clinical practice standards.</li>
<li>Utilizes standardized assessments and evidence-based practice to support clinical interventions.</li>
<li>Provides rehabilitative, skilled and medically necessary treatment intervention to patients with cognitive and/or ADL physical functioning disorders per regulatory and clinical practice requirements.</li>
<li>Administers various procedures as part of the rehabilitation plan including but not limited to: ADL retraining; therapeutic activities; therapeutic exercises; modalities; use of supportive and assistive devices; etc.</li>
<li>Assesses patient&rsquo;s progress and adjust treatments accordingly in the clinical record per regulatory and clinical practice requirements.</li>
<li>Evaluates treatment outcomes for effectiveness. Services are modified in relation to patient evaluation and referrals are made in relation to outcomes.</li>
<li>Provides consultation and counseling to patients, as well as families, caregivers and other service providers related to the physical disorders.</li>
<li>Effectively communicates with supervisor and other health team members regarding patient progress, barriers, and treatment plans.</li>
<li>Provides comprehensive discharge summary of services provided per regulatory and clinical requirements.</li>
</ul></div><div><b>Qualifications:</b></div>
<div>Occupational Therapist license is required.</div>
<div><div><div>Open to Occupational Therapists at all experience levels. New Grads are welcome!</div>
</div>
</div><div></div><div><b>At Olympia, we believe that exceptional care starts with a strong set of values that guide everything we do. As a Occupational Therapist with us, you&rsquo;ll be part of a team that helps drive the CAPLICO values:</b></div>
<div><b>Customer Second:</b> We put our team first, knowing that when we take care of each other, we can better serve our clients.</div>
<div><b>Accountability:</b> We take ownership of our actions and are dedicated to delivering the highest quality care.</div>
<div><b>Passion for Learning:</b> We are always growing and improving, embracing new knowledge to enhance our skills and stay at the forefront of physical therapy.</div>
<div><b>Love One Another:</b> We create a supportive and caring environment where everyone feels valued, respected, and empowered.</div>
<div><b>Intelligent Risk-Taking:</b> We are not afraid to challenge the status quo to create innovative solutions for our patients and our practice.</div>
<div><b>Celebration: </b>We celebrate successes, big and small, and recognize the hard work and dedication of our team members.</div>
<div><b>Ownership: </b>We take full responsibility for our roles, contributing to a shared vision of excellence in patient care.</div>
<div></div><div><b>Browse our website at www.FlagshipTherapy.com and find out why we are truly different in dignifying long term and post-acute care.</b></div>
<div></div><div><b>Benefits:</b></div>
 <ul><li>Medical, Dental, Vision Insurance (Blue Cross Blue Shield)</li>
 <li>401k w/ Match</li>
 <li>Paid Time Off</li>
 <li>Live Unlimited CEU Opportunities</li>
 <li>Career Advancement Opportunities</li>
 <li>Tuition Reimbursement</li>
 <li>Scholarship Opportunities</li>
 <li>Employee discounts on gym memberships, entertainment events, hotels, movies, theme parks, cell phones, and much more!</li>
</ul><div><b>For benefit details check us out here http://ensignbenefits.com/</b></div>
<div><b>Eligibility for some benefits dependent on full time employment status.</b></div>
<div></div><div><b>Disclaimer: </b>Pay rates are competitive and determined by various factors. Please note that any rates labeled as &quot;estimated&quot; are provided by third-party job boards and may not accurately reflect the actual pay rates.</div>
<div></div><div>We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, sexual orientation, gender identity, national origin, disability or veteran status.</div></div></div></div></div></div></div></div>

Occupational Therapist - Olympia Transitional Care

Klamath Tribal Health & Family Services

<div>Description:
<p>
The primary objective is to identify available support services in Klamath County and/or through The Klamath Tribes. The Case Manager will build relationships with participants and provide information on utilization requirements for receiving identified services. The Transitional Emergency Shelter Case Manager will work with participant to provide intensive case management services in collaboration with KTHFS programs such as medical clinic, dental clinic and behavioral health clinic.</p><p>
The TES Case Manager will identify the potential need for additional services for Klamath Tribal Health &amp; Family Services (KTHFS) based on established intake and screening assessments for eligible participants on a case-by-case basis and will provide assistance, to those identified, with access and coordination of appropriate services.</p><p>
The TES Case Manager must have the ability to work with participants in distress and/or crisis. This position will work directly with the at-risk homeless population and must be skilled in de-escalation and mental health support techniques.</p>
Requirements:
<p><b>
Minimum Qualifications:</b> <b><i>Failure to comply with minimum position requirements may result in termination of employment.</i></b></p><ul><li><b>REQUIRED </b>to possess a High School Diploma or Equivalent.</li><li><b>REQUIRED</b> to have at least two years&rsquo; work, education, training or related experience in case management or working with participants/clients/patients in a health or related field<b>. (</b><b><i>Must submit copy of diploma or transcripts with application.)</i></b></li><li><b>REQUIRED</b>, to have one year of experience working with service populations providing direct case management, including conducting in-depth interviews with individuals, formulating social service treatment plans, providing ongoing social work support and counseling, and coordinating service delivery with other agencies.</li><li><b>REQUIRED</b> to obtain a clinical certification within two years of hire or job reclassification. This could include a CADC, Peer Support Specialist, Recovery Mentor Certification, a Qualified Mental Health Associate (QMHA) or other certification.</li><li><b>REQUIRED</b> to understand, communicate and comply with the expectations and requirements of a variety of agencies.</li><li><b>REQUIRED,</b> Computer experience. Emphasis will be in the use of Microsoft Word, Excel, Outlook, Microsoft Teams, and work in a networked environment.</li><li><b>REQUIRED</b> to possess and maintain a valid Oregon Driver&rsquo;s License, <b>(out of state</b> <b>applicants must receive ODL within 90 days of hire),</b> have good driving record and be insurable by the Klamath Tribal Health &amp; Family Services&rsquo; vehicle insurance policy. Must be able to drive in adverse weather conditions. <b>(</b><b><i>Must submit copy of driver license with application.)</i></b></li><li><b>REQUIRED</b> to maintain strict confidentiality of protected health information in accordance with regulations.</li><li><b>REQUIRED</b> to submit to annual TB skin testing and adhere to KTHFS staff immunization policy in accordance with the Centers for Disease Control immunization recommendations for healthcare workers.</li><li><b>REQUIRED </b>to acquire and maintain BLS certification within 180 days of hire; strongly recommend certification within 90 days of hire, probationary period will be extended for a maximum of 180 days pending certification.</li><li><b>REQUIRED</b> to model a clean and sober lifestyle both on and off the job. Have a minimum of 2 years clean and sober from any substance abuse issues.</li><li><b>REQUIRED </b>to be free from exclusion from providing Federal health care benefits including Medicare and Medicaid as per the Federal OIG and GSA exclusion lists.</li><li><b>REQUIRED </b>to accept the responsibility of a <b>Mandatory Reporter</b> in accordance with the Klamath Tribes Juvenile Ordinance Title 2, Chapter 15.64 and General Council Resolution #2005 003, all Tribal staff are considered mandatory reporters.</li></ul></div>

Transitional Emergency Case Manager

Hanna Center

<div><p>Job Title: Case Manager, Transitional Programs &amp; Alumni Relations</p><div>
FLSA Classification: Salary Exempt, Non-Exempt Salary: Based on Experience</div><div>
Department: Alumni/Follow-On/THP</div><div>
Reports to: Director of Transitional Programs &amp; Alumni Relations</div><div>
Updated: February 2026</div><p></p><h2 class="jobSectionHeader"><b><br>
Job Summary</b></h2><p>
This position is responsible for the implementation and growth of the program as it pertains to the guidance and support of current and former participants.</p><h2 class="jobSectionHeader"><b>
Essential Functions</b></h2><ul><li>Provide individualized case management to assigned participants, ensuring goal-oriented service planning, resource coordination, progress monitoring, and timely documentation to support progress toward identified goals.</li></ul><p>
- Adapt service plans as crises arise, exercising sound judgment and flexibility in response to changing participant needs. -Serve as a resource to current participants in preparation for leaving the Center by guiding them in their development of independent living skills.</p><ul><li>Oversee the implementation and growth of the Follow-On Program for participants graduating from Hanna Center/Academy programs.</li><li>Assist in the oversight of the Hanna Center scholarship platform by assisting with the application process and preparing recommendations for the scholarship committee.</li><li>Support recipients in the scholarship program through visits with them, their schools and colleges, counselors, and families and by establishing personal contact through correspondence, e-mail, or telephone, aiding as appropriate.</li><li>Provide as needed, counseling, crisis intervention, career guidance, or community resource recommendations for alumni.</li><li>Participate in the graduation committee meetings.</li><li>Collaborate with vocational education/career counseling, arranging for off-campus career development and on-campus guest speakers.</li><li>Develop professional relationships with schools and outside agencies.</li><li>Participate in ongoing assessment of the follow-on/alumni program, so as to provide for evolving changes and needs, if necessary, to ensure its effectiveness as a vital resource for guiding and supporting current and former participants of Hanna Center to become self-reliant, successful and productive with moral values in their lives and careers.</li><li>Assist in the management of the yearly department budget.</li><li>Oversee and manage the databases used for outcome measures of current and former participants.</li><li>Participate in Department-sponsored events.</li><li>Demonstrate exceptional organizational skills</li><li>Ability to effectively multitask, and the flexibility to deviate from service plans as crises arise.</li><li>Possess working knowledge of DMV procedures, college registration processes, legal support systems, and community-based organizations to effectively connect participants with appropriate resources and supports.</li><li>Coach and mentorship skills</li><li>Networking and relationship building</li><li>Independent self-starters with the ability to work collaboratively</li></ul><h2 class="jobSectionHeader"><b>
Supervisory Responsibilities</b></h2><ul><li>This position has no direct reports</li></ul><h2 class="jobSectionHeader"><b>
Core Competencies</b></h2><ul><li>Ability to implement the follow-on/alumni program.</li><li>Maintain confidentiality at the highest level in accordance with agency policies and legal requirements.</li><li>Knowledge of the Hanna Scholarship program</li><li>Knowledge of Salesforce and data collection and input</li><li>Knowledge of crisis intervention, career guidance, or community resource</li><li>Knowledge of independent living skills</li><li>Knowledge of Scholarship and career development</li></ul><h2 class="jobSectionHeader"><b>
Work Environment</b></h2><p>
Typical office environment, with on-site responsibilities in Sonoma. May require offsite meetings, conferences, or training.</p><h2 class="jobSectionHeader"><b>
Physical Demands</b></h2><p>
Lift and/or carry up to 20 lbs. (occasionally)</p><p>
Clear background check, pre-employment drug screening, and TB test</p><p>
Sit for a prolonged period with the ability to perform repetitive movements.</p><h2 class="jobSectionHeader"><b>
Education and Experience</b></h2><p>
Childcare and/or youth residential settings</p><p>
Bachelor's degree in social science or comparable experience</p><h2 class="jobSectionHeader"><b>
Additional Eligibility Requirements</b></h2><p>
Certified or ability to become certified in CPR, First Aid, and Community Water Safety</p><p>
Valid California driver&rsquo;s license with the ability to become insured under company policy</p><p>
Complete Mandated Child Abuse Reporting, Ethical Standards, Crossing Boundaries of Employee Conduct</p><h2 class="jobSectionHeader"><b>
Affirmative Action/EEO Statement</b></h2><p>
Hanna is an equal opportunity employer. All applicants will be considered for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran, or disability status.</p><h2 class="jobSectionHeader"><b>
Other Duties</b></h2><p>
This job description is not exhaustive and may be subject to change at any time. Other duties may be assigned as needed to support organizational goals.</p></div>

Case Manager, Transitional Program & Alumni R

Recruiter for Healthcare

<p><b>Job Summary</b></p><p>This role is community-based, focusing on providing both urgent and primary care to our members where they live. Working in partnership with the member&rsquo;s primary care provider and interdisciplinary team, the community-based provider is responsible for seeing members recently discharged from the hospital and ensuring a smooth transition of care to prevent readmissions, seeing members who have urgent clinical needs and addressing them so they can avoid a trip to the Emergency Room, and performing chronic disease management and preventive care in conjunction with the center-based primary care team.</p><p><b>Duties and Responsibilities</b></p><ul><li>Provide community-based medical and care-coordination services for recent hospital discharges</li><li>Work closely with the transitional care manager and the member&rsquo;s primary care team, following through on the discharge plan with the member.</li><li>Conduct patient/member assessments.</li><li>Review, monitor, adjust and discontinue medications.</li><li>Comprehensive Medication Review for adherence.</li><li>Patient/Member and family education.</li><li>Coordinate home care agencies and services.</li><li>Develop and implement plan of care.</li><li>Communicate patient&rsquo;s medical, or mental conditions, substance abuse and social determinants of health needs.</li><li>Document appropriately in the Electronic Medical Record.</li><li>Gather critical information from member&rsquo;s home environment and coordinates use of this information with healthcare team.</li><li>Work collaboratively with the primary care provider, interdisciplinary office care team and transitional care manager,</li><li>Support safe discharge transition and treatment in the community.</li><li>Intervene with at-risk members to avoid unnecessary hospitalizations.</li><li>Coordinate with care team, patient/member, family, and caregivers to help resolve barriers to care and transition back to Medical Center setting.</li><li>Maintain the security and privacy of all information that is owned by or maintained on behalf of the company&rsquo;s patients, employees, and business partners.</li></ul><p><b>Qualifications:</b></p><ul><li>2+ years as a Nurse Practitioner or Physician Assistant</li><li>Familiar with care transitions, strategies for reducing readmissions and chronic condition management interventions</li><li>Knowledge of local population, geography, and resources.</li><li>Knowledge and experience using Electronic Medical Records and ability to analyze and leverage their reporting capabilities.</li><li>Excellent computer skills, including knowledge of Microsoft Office.</li><li>Experience working with high risk and medically complex patients with multiple comorbidities preferred.</li><li>Psychiatric and substance use disorder experience preferred.</li></ul><p>Pay: From $150,000.00 per year</p><p>Benefits:</p><ul><li>401(k)</li><li>Dental insurance</li><li>Health insurance</li><li>Paid time off</li><li>Vision insurance</li></ul><p>Work Location: In person</p>

Advanced Practice Provider, Community Based

Evergreen Nephrology

<div><p><b>Who We Are</b></p>
<p>
Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, holistic, and comprehensive approach to kidney care. We believe patients living with kidney disease deserve the best care. We are committed to improving patient outcomes and improving quality of life by delaying disease progression, shifting care to the home, and accelerating kidney transplants.</p>
<p>
We help nephrologists focus on the right patients at the right time across the full care spectrum. We do this by providing them with the best-in-class interdisciplinary clinical resources, analytical insight and tools, and services to patients. We listen to the needs of our patients, our employees, and our client partners, continually working to push beyond the status quo in which the care system manages patients today.</p>
<p><b>
Who You Are</b></p>
<p>
You are devoted, compassionate, and enjoy being on the front lines of healthcare, changing the lives of patients by supporting them and the team by focusing on customers. You're excited about being part of a team that is building a healthcare delivery model that ensures the highest possible quality of life and best outcomes for those in our care. You believe people living with kidney disease deserve the best person-centered, holistic, comprehensive care and want to influence the healthcare system to drive towards that. You thrive in innovative and evolving environments with high rates of change.</p>
<p><b>
Your Role</b></p>
<p>
As the Program Manager of Chronic and Complex Patient Management (CCPM) and Transitions of Care (TOC) with Evergreen Nephrology, you will lead a team focused on delivering longitudinal, patient-centered care for individuals with complex and chronic conditions, including kidney disease, diabetes, heart failure, and other comorbidities. In this role, you will provide collaborative, supportive leadership and oversee the day-to-day operations of the care management team, ensuring consistent execution of proactive care strategies that improve patient outcomes. You will leverage your clinical and operational expertise to guide the management of high-risk populations, ensure adherence to established care pathways, and reduce complications, avoidable hospital admissions, and overall healthcare utilization. You will be accountable for CCPM and TOC program performance, driving results against key performance indicators (KPIs) and quality metrics. Additionally, you will support ongoing team development through coaching, training, and performance management to ensure delivery of high-quality, efficient, and patient-centered care aligned with Evergreen's standards.</p>
<p><b>
Role Responsibilities</b></p>
<ul>
<li>Oversee day-to-day operations for the CCPM and TOC care management teams, ensuring efficient workflows, standardized processes, and consistent achievement of program goals.</li>
<li>Ensure delivery of high-quality longitudinal chronic/complex care management and best-in-class transitions of care, including adherence to clinical pathways, protocols, and documentation standards.</li>
<li>Continuously evaluate and improve the performance of CCPM and TOC programs and team members, consistent with Evergreen's performance management philosophy.</li>
<li>Develop and implement collaborative strategies to improve program performance and patient outcomes (e.g., chronic disease control, complication prevention, and reduced readmissions) while ensuring patient and provider partner satisfaction.</li>
<li>Support newly hired CCPM/TOC team members through orientation and onboarding; provide ongoing training, coaching, and development for established team members.</li>
<li>Perform regular call and documentation (chart) audits to support performance management and identify opportunities for continuous improvement.</li>
<li>Prepare performance reports, dashboards (as applicable), and meeting materials for CCPM and TOC programs for internal and external audiences.</li>
<li>Oversee TOC workflows that support timely post-discharge outreach, medication reconciliation support, follow-up appointment coordination, and issue escalation to reduce avoidable readmissions.</li>
<li>Develop and foster relationships with key stakeholders (e.g., IDT members, market leaders, and other program leaders) to drive outcomes through collaboration and cross-program partnership across CCPM and TOC.</li>
<li>Build and maintain effective communication strategies between Evergreen and market stakeholders to foster strong relationships that support improved patient outcomes, in collaboration with market leaders.</li>
<li>Be a Culture Champion by cultivating a culture of high performance, transparency, trust, and collaboration.</li>
<li>Other duties consistent with this role, as assigned.</li>
</ul>
<p><b>Required Qualifications</b></p>
<ul>
<li>Bachelor's degree in healthcare or nursing (BSN required)</li>
<li>Active state nursing license in good standing</li>
<li>3+ years of longitudinal clinical nursing care management experience required</li>
<li>2+ years of experience in a clinical nursing managerial or leadership role</li>
<li>Experience in longitudinal care management</li>
<li>Strong business acumen of value-based healthcare operations in disease management and population health programs</li>
<li>Understanding of Business Continuity and how to build resiliency into business processes / systems</li>
<li>Ability to develop talent, know when to delegate, innovate and iterate with your team, leveraging their strengths</li>
<li>Exceptional relationship-building, communication, and change management skills, with the ability to influence effectively and establish trust and credibility quickly with internal and external partners</li>
<li>Strong leadership presence which inspires others and instills confidence in peers, external partners, board members, and team members</li>
<li>Execution-focused and hands-on, with the ability to effectively balance strategic priorities and detailed, day-to-day operational work (&quot;in the weeds&quot;).
</li><li>Able to motivate staff; influence people and outcomes, you promote team building</li>
<li>Demonstrated ability to work effectively independently and as part of a team, in collaborative settings</li>
<li>Commitment to maintaining highest level of confidentiality</li>
<li>Organizational skills, operational rigor, resilience, and commitment to the business</li>
<li>Intermediate skills with MS Office Suite of products including Outlook and Teams</li>
<li>Able to work effectively in a primarily remote environment:
<ul><li>Home internet must support a minimum download speed of 25 Mbps and upload speed of 10 Mbps. Cable, Fiber, or DSL connections hardwired to the internet device are recommended</li>
<li>Evergreen will provide remote employees with telephony applications and equipment to meet the business requirements for their role</li>
<li>Employees must work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information</li></ul></li><br>
</ul>
<p></p><p><b>Preferred Qualifications</b></p>
<ul>
<li>Master's Degree in Nursing or Healthcare Administration or related field</li>
<li>Experience with quality improvement using data to track and improve program performance</li>
<li>Previous experience working within a managed care environment especially with experience in administrative/management capacity</li>
<li>Experience in leading the clinical function of a Value Based Care organization</li>
</ul>
<p><b>Compensation</b></p>
<p>
The pay range for this role is $110,000 to $115,000 annually. Exact pay is determined based on experience, education, demand for the role, and other role-specific factors.</p>
<p>
This role is also eligible for an annual bonus.</p>
<p><b>
Benefits
</b></p><p>Evergreen Nephrology's total rewards program is designed to support you in and outside of work. You can expect:</p>
<ul>
<li>Paid time off starting at 4 weeks for full-time employees</li>
<li>12 paid holidays per year</li>
<li>Medical, dental, vision and life insurance, including an HSA with employer match</li>
<li>Reimbursement for continuing medical education for eligible roles</li>
<li>A 401(k) program where Evergreen matches up to 4% of contributions after six months of tenure</li>
<li>Paid parental leave</li>
<li>A robust training and development program that starts with onboarding and continues throughout your career with Evergreen Nephrology</li></ul><br>
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Evergreen Nephrology is an equal opportunity employer. Applicants will not be discriminated against because of race, color, creed, sex, sexual orientation, gender identity or expression, age, religion, national origin, citizenship status, disability, ancestry, marital status, veteran status, medical condition or any other protected category under local, state or federal laws.</p><br>
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If you are an applicant with a disability who requires reasonable accommodation for any part of the hiring process, please contact us for assistance at recruiting@evergreennephrology.com.</p></div>

Program Manager - Chronic and Complex Care Management & Transitions of Care

EA Family Services

EA Family Services (formerly Environmental Alternatives) is seeking a full-time Case Manager for our Transitional Housing Plus Foster Care (THP+FC) program for young adults ages 18-21 in our Sacramento office. BA/BS degree in social work or related field required. EA is seeking team players who are highly motivated and passionate about working with young adults. Excellent communication skills are a must.
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DOJ/FBI/CAIC clearances required. Excellent benefits package available. $23.00 per hour. OCA# 347006625 EOE

Case Manager

Search 10000+ Transitional care manager jobs near you this March. New roles added regularly across leading industries. Apply today.