Job Summary
The Integra Transition Manager collaborates with a group of Physicians to pursue cost-effective, quality focused management interventions by achieving a predetermined financial and clinical outcome. Responsible for providing ongoing communication with patients, continuing care coordinators, social workers, and physicians to ensure patients have appropriate resources/support in the community and intervening when patients are unable to be managed adequately. Tracks patients along with continuum of care, identifying patterns that have a negative cost-quality impact and assists with the development of plans for improving care.
Duties & Responsibilities
1. Applies Case Management principles to the acute care in-patient population to ensure appropriate utilization of resources and level of care. This includes assessing, planning, implementing, coordinating, evaluating and collaborating with the interdisciplinary team, patients, families and community providers.
2. Assists in the facilitation of discharge planning for Integra ACO patients with Care Coordination who are in observation or admitted status from the acute care setting. This may include but is not limited to, acute rehabilitation admission, transfer to a skilled nursing facility, initiation or resumption of visiting nurse services, referral to other outpatient providers, transportation and initiation of outpatient Infusion therapy.
3. Assists in the facilitation of patient flow with Care Coordination by identifying barriers and working with the interdisciplinary care team to improve.
4. Assists in the identification of patients for Case Management and Social Service referrals during the review process.
5. Completes all documentation in a timely manner in Epic and Cerner.
6. Acts as a resource to the ED Hospital Liaison.
7. Engage in process improvement activities that are focused on efficient care delivery and promotes positive clinical and quality outcomes including reducing unnecessary admissions, readmission rates and flow metrics.
8. Protects and preserves patient confidentiality at all times.
9. Performs related duties as required
Requirements
• Registered Nurse with Bachelors Degree in Nursing or equivalent, with current RI license.
• Minimum of 5 years related clinical Acute Care or Case Management experience required.
• Knowledge of utilization review, quality assurance, discharge planning, third party payor regulations and community health.
• Experience demonstrating high level of interpersonal skills, both oral and written, analytical skills, leadership abilities and effectiveness within a team environment.
