Care Transitions Manager RN, Skilled Nursing & Case Management
Overview
You will own care transitions for residents in our skilled nursing community, cutting hospital readmissions through personalized coaching and coordination. You report to the Director of Nursing and supervise an assigned nursing team. You'll partner with acute and post-acute providers, residents and families, implementing INTERACT tools and PAM assessments to drive quality outcomes. This role stands out for its focus on person-centered care and integration with Masterpiece Living and Eden Alternative initiatives.
What You'll Do10
- 1Coordinate interdisciplinary team efforts to meet resident goals and expectations, using INTERACT tools to improve care practices and communication.
- 2Perform post-admission screenings to gauge resident knowledge of disease processes and administer the PAM assessment to establish baseline activation.
- 3Coach residents and stakeholders to actively participate in care plans, setting measurable goals that reduce readmission risk.
- 4Lead care conferences, care plan updates and Med A meetings, aligning discharge plans with rehabilitation and transition goals.
- 5Oversee discharge planning and case management, implementing resident education materials and disease management teaching.
- 6Evaluate resident readmissions and recommend QAPI improvements, acting on quality indicator reports and initiating corrective actions.
- 7Identify residents needing advanced care planning, initiating palliative or hospice care conversations.
- 8Supervise nursing staff, providing coaching, training, corrective action, and performance appraisals.
- 9Manage rehabilitation services, including vendor relationships and team competencies.
- 10Act as Director of Nursing in their absence, ensuring regulatory compliance and clinical oversight.
Requirements9
- 1RN license in good standing required; BSN preferred.
- 22+ years of nursing experience as an RN or LPN.
- 31-3 years in a supervisory capacity required.
- 4Knowledge of state and federal laws for skilled nursing facility operations in Colorado.
- 5Expertise in PPS, MDS, OBRA and OSHA preferred.
- 6Experience with long-term care and hospital settings, understanding technology's role in resident care.
- 7Computer proficiency with word processing and database software.
- 8Excellent customer service and communication skills, including reading, writing and speaking English.
- 9Ability to handle objects up to 20 pounds occasionally and 10 pounds frequently.
Salary Insight
$100 - $108k per year
Location
Required Skills
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