Primary City/State:Innovation Care Partners - 8901 E Mountain View Rd Scottsdale, AZ 85258
Category:Case Management
Shift:Day
Department:Care Management
Up to 10,000.00 Sign On Bonus Available8:00 - 4:30Responsibilities:JOB SUMMARY
The Complex and Transitional Care Manager is responsible for managing the care of high-risk, medically complex patients throughout the continuum of care. This includes both chronic condition management and transitional support during care transitions (e.g., hospital discharge, rehab, home care). The goal is to improve clinical outcomes, reduce avoidable readmissions, and support safe, patient-centered care.
ESSENTIAL FUNCTIONS
- Coordinate patient transitions between hospitals, skilled nursing facilities (SNFs), home health, primary care, and specialists.
- Conduct timely patient post-discharge follow-ups via telephonic calls or in-home visits, as warranted.
- Facilitate patient/caregiver education at transitions of care and chronic care management.
- Develop and implement individualized care plans and transition plans in collaboration with patient/caregiver, PCP and embedded Care Coordinators.
- Monitor progress toward goals, adjust care plans as needed, and advocate for access to appropriate services.
- Document assessments, care plans, and interventions in the electronic medical record (EMR) accurately and in a timely manner.
- Collaborate with the Chief Medical Officer, providers, primary care, embedded Care Coordinators and other health care professionals/agencies to ensure complex outpatient care is coordinated across the health care continuum
- Participate in quality improvement initiative related to care transitions, chronic disease management, and utilization reduction.
- Mentors as a buddy for new Care Mangers and Care Coordinators.
- Is key in developing PCP and embedded Care Coordinator relationships and education on Care Management program.
- Maintain all regulatory educational requirements by participating in continuing education activities.
- Demonstrate professional behavior and promotes cooperation and team building.
- Maintain and manage to their caseload
- Support and participate in the development and maintenance of scorecard.
- Maintain accurate metric tracking for daily productivity management.
- Perform other duties or responsibilities as assigned by people leader to meet business needs
EDUCATION
- Bachelors Nursing Required
- Masters Nursing Preferred
EXPERIENCE
- 2 years as Case (or Care) Manager, Transitional Care Manager, Care Coordinator RN or Nurse Advocate Required
- 3 years Registered Nurse Preferred
LICENSE AND CERTIFICATIONS
- Registered Nurse (RN) - License State And /Or Compact State Licensure Required
- Basic Life Support (BLS) - Certification Required
- Fingerprint Clearance Card (FPC) - Certificate Required
- Certified Case Manager - Certification Preferred or
- Accredited Case Manager (ACM) - Certification Preferred
- Certification in Healthcare - nursing or other healthcare field Preferred
