Transition of Care Nurse Care Manager, NY RN License
Overview
Own transitional care for patients moving between facilities, ensuring smooth relocations and reducing readmissions. Work within the Transitional Care Model (TCM) at SVCMC Inc in New York. Coordinate with clinical teams, utilization management, and external agencies to drive safe discharges. Act as patient advocate and educator. This role blends clinical expertise with care coordination, requiring quick decisions and proactive follow-through.
What You'll Do6
- 1Coordinate discharge planning with the inpatient clinical team at admission, ensuring safe transitions. Document progress notes in USFHP database.
- 2Review clinicals with the utilization management team to monitor member progress and determine discharge plans. Ensure follow-ups, medication access, and needed resources.
- 3Act as patient advocate, negotiating resources with payers, agencies, and vendors. Educate physicians and care managers on utilization review issues like inappropriate admissions.
- 4Assist hospital staff in creating discharge plans that address needs and barriers. Assess member readiness for discharge.
- 5Conduct outreach within 24 hours post-discharge from hospital, E.R., or skilled nursing stay. Support medication reconciliation and compliance, and ensure follow-up with MD within a week.
- 6Document all communications and member conditions in the computer database. Drive seamless transitions to reduce relapse and readmission.
Requirements7
- 12+ years of Medical Surgical experience.
- 2Bachelor's Degree required.
- 3Current and unrestricted NYS RN License and Registration. Ability to obtain RN licenses in CT, PA, and NJ.
- 4Experience in utilization review processes and UM review.
- 5Discharge planning and case management experience.
- 6Flexible and willing to work in a dynamic role. Proactive team player with strong follow-through.
- 7Quick decision-making and strong problem-solving skills.
Salary Insight
$95 - $100k per year
Location
Required Skills
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