Transitional Care Manager

Salary Range $85,000 - $90,000 per year

Why Work at AbsoluteCare?

At AbsoluteCare, we serve the most vulnerable individuals in America. These are our neighbors, people who are at higher risk for disease or who have multiple, complex, chronic illnesses. Often, they deal with an unequal healthcare system and wind up seeking basic care from emergency rooms. We take these patients out of those spaces and turn them into members: people who are entitled to some of the best, most focused care this country has to offer.

We call this “care beyond medicine.” We have turned the doctor’s office into a comprehensive care center. Here, we surround our members with a core care team of doctors, nurses, social workers, and medical assistants who have the time and skills to get to know our members’ needs. We make the most important services available to our members under one roof. This includes a pharmacy, X-rays, a blood lab, nutrition services, urgent care, and much more.

We don’t stop at our four walls. We engage members in the communities where we all live to find the people who need us most. Through these community care teams, we remove the barriers to healthcare that so many people face daily. And it works.

Our unique care is guided by our core values of accountability, caring, trust, and teamwork. We call it ACT2.

Job Summary

This role is a member of the integrated community care team (ICCT), providing in-person discharge planning, care coordination and integrated case management supports for members currently admitted at a facility (Acute, BH, SNF, Rehab…). The transitional care manager (TCM) is assigned to acute and post-acute facilities in the community. TCMs are assigned to the members at the time of admission and care coordinate for their complex medical, behavioral, and social determinants of health needs to reduce readmissions and help manage length of stay. Working in partnership with the facility and the health plan, the TCM coordinates care in collaboration with AbsoluteCare Medical Director and primary care providers, community primary care providers and specialists and local community resource and service agencies required to meet the member’s individual post discharge needs. TCM effectiveness is measured by value-based care outcomes including admission and readmission rates, length of stay, length of stay and hospital follow-up completion rates.

Duties and Responsibilities

• Meet in person with members during their inpatient admission and develop a person-centered care plan (PCCP) to address their discharge and care transition needs.

• Call members post discharge to review discharge instructions, complete medication reconciliation and ensure scheduling of hospital follow-up visits.

• Coordinate member post discharge plans including hospital follow-up with primary care provider and specialists, home health, durable medical equipment, medications, social and caregiver supports.

• Leverage evidence-based guidelines, i.e. Milliman Care Guidelines (MCG), to manage appropriate site of service to deliver care (inpatient, SNF, Rehab, home…) and appropriate length of stay.

• Assist building and maintaining hospital/facility relationships and through the relationships influence alternate care and discharge planning to manage site of service and length of stay.

• Communicate with AbsoluteCare team and community primary care providers on a regular basis, review assigned member discharge plans and barriers to a safe discharge.

• Manage PCCP and member contact in compliance with all agency requirements, internal protocols, and accreditation standards.

• Provide education with teach back regarding medical, behavioral, and functional health conditions, symptoms, and treatment options.

• Provide evidence-based clinical interventions centered on established person-centered care plan goals using a variety of approaches, e.g., trauma informed care, harm reduction, behavior change modalities, motivational interviewing, teach back methods and problem solving.

• Attend clinical rounds with health plan partners, review PCCPs for discharge, provide recommendations for appropriate level of care and next steps to expedite care transitions.

• Meet established Key Performance Indicators.

• Manage assigned caseload based on visit and contact frequency requirements and utilization data.

• Proactively mitigate/resolve barriers to care to increase adherence to discharge plan and reduce risk of readmission.

• Assist members in accessing and engaging with AbsoluteCare and community services and resources and follow up on member adherence to referrals.

• Actively participate in required meetings.

• Other duties as assigned to meet business needs.

• Maintain the security and privacy of all information that is owned by AbsoluteCare or maintained on behalf of the company’s patients, employees, and business partners.

• Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.

• This description reflects management’s assignment of essential functions; it does not proscribe or restrict the tasks that may be assigned.

• This job description is subject to change at any time.

Minimum Qualifications

• A minimum of 80% of this role’s time is spent onsite in hospitals, skilled nursing facilities and/or residential treatment facilities to engage members and build relationships with facility discharge planners and case management staff.

• CPR/BLS certification required.

• Licensed RN by the state in which practicing and abide by all laws, regulations, and requirements.

• Highly desirable preference given to RN candidates with extensive experience discharge planning, care transition coordination and medical and behavioral case management in the community. Candidate with CCM or CCTM credentials a plus. LMSW with similar job experience and certifications will be considered.

• 3+ years of experience in serving the needs of complex populations, including medically complex, trauma history, mental health conditions, substance use, and socioeconomic barriers in an office or community-based setting.

• Preference given to qualified candidates with multiple settings experience (Inpatient, LTPAC, home health, corrections, community programs and/or human service agencies.)

• Experience with complex government-sponsored populations preferred, e.g., Medicaid, Medicare beneficiaries.

• Experience with member engagement, transitions of care, clinical care, and/or case management

• Experienced in discharge planning and care coordination for continuity in care transitions, strategies for reducing readmissions and chronic condition management interventions a must.

• Experienced in concurrent review for level of care determinations and taking action to transition to other care settings by expediting prior authorizations, leveraging the power of influence, and advocating on behalf of the member. Familiarity with MCG and ASAM criteria a plus.

• Ability to take a creative and innovative approach to problem-solving to aid patients in overcoming barriers to care transitions.

• Excellent computer skills including Microsoft Office Suite (Outlook, Excel, PowerPoint, Word) and electronic medical record documentation required.

• Excellent written and oral communication skills to interact with members, families, community stakeholders, and interdisciplinary team required.

• Ability to meet accreditation and quality standards including, but not limited to NCQA, PCMH, HEDIS through following defined procedures to assess, intervene and document interactions.

• Ability to work independently and exercise excellent clinical judgement.

• Active unencumbered driver’s license, with automobile insurance, reliable transportation, and ability to work in office and in the community.

• Second language ability is desirable relevant to local population, geography, resources.

• CPR certification

Working conditions

This job operates in the community, hospitals, healthcare facilities and within a professional office environment. This role requires reliable transportation to commute back and forth between inpatient facilities and office; and routinely uses general office equipment.

Physical requirements

• Ability to communicate clearly and exchange accurate information consistently.

• Ability to remain stationary for long periods of time.

• Repetitious movements.

• Constantly operates computer, keyboard, copy and fax machine, phone, and other general office equipment.

• Ability to occasionally move objects up to 20 lbs.

Direct reports

None.