We are Emerus, the leader in small-format hospitals. We partner with respected and like-minded health systems who share our mission: To provide the care patients need, in the neighborhoods they live, by teams they trust. Our growing number of amazing partners includes Allegheny Health Network, Ascension, Baptist Health System, Baylor Scott & White Health, ChristianaCare, Dignity Health St. Rose Dominican, The Hospitals of Providence, INTEGRIS Health, MultiCare and WellSpan. Our innovative hospitals are fully accredited and provide highly individualized care. Emerus' commitment to patient care extends far beyond the confines of societal norms. We believe that every individual who walks through our doors deserves compassionate, comprehensive care, regardless of their background, identity, or circumstances. We are committed to fostering a work environment focused on teamwork that celebrates diversity, promotes equity and ensures equal access to information, development and opportunity for all of our Healthcare Pros.
Position OverviewThe purpose of this position is to manage a patient’s successful transition from hospital to home. The Transitional Care Manager is responsible for practicing in a high-quality, patient-centered, systematic, and evidence-based approach of assessment, diagnosis, planning, implementation and evaluation for all Emerus patients. As a member of the multidisciplinary health team, the Transitional Care Manager identifies high-risk, complex patients for program enrollment and communicates with all entities involved in the care of the patient to promote and maximize high-quality care coordination. The practice of this position has a direct impact on patient outcomes and Hospital performance measure for Medicare and Medicaid compliance.
Essential Job Functions Holistic patient assessment for discharge planning needsParticipate in hospital multidisciplinary daily roundsIdentify patient and family education needs to ensure adequate participation in discharge planningIdentify patient concerns regarding discharge, social risk factors and anticipate potential gaps in careManage patient coordination of care across the care continuum Utilize research findings in practice, and participate in program development and implementation Coordinate with Hospitalists and advance practitioners to bridge care gapsEngagement of appropriate agencies or community resources when high-risk patients are identifiedEvaluate and update market Discharge Planning Resource to meet the market’s healthcare disparity needs Establish and maintain professional relationships with physicians, nursing, county agencies, community resources, patients and their support system Facilitate decisions and communicate effectively regarding transitional care plansMaintain regulatory compliance with CMS Conditions of Participation and DNV NIAHO Accreditation RequirementsMaintain a working knowledge of community resources related to professional scope of practiceKnowledge of behavioral health systems, neglect and violence authority agencies, and community or financial resources for underserved or vulnerable populations Maintain patient health information privacy at all times and abide by company policies Functions as a liaison between the interdisciplinary treatment team and community partnersPerform patient telehealth assessmentsUtilize financial and insurance resources to maximize the healthcare benefit to the patient Arrange post-discharge medical and community referrals for patients with health problems requiring further evaluation and/or additional servicesApply advanced critical thinking and conflict resolution skills Other Job Functions Excellent customer service and presentation skillsWillingness to be a valued member on a team with an inspiring missionAbility to establish and maintain collaborative, effective working relationshipsAbility to communicate professionally and effectively in all platforms and forums Attend staff meetings or other company sponsored or mandated meetings as requiredAbility to manage multiple tasks simultaneouslyDemonstrate professional organization skillsPerform additional duties as assignedAbility to work off-hours and on call when required Proficiency with Microsoft Office (Excel, Word, PowerPoint, TEAMS, OneDrive, and Outlook), requiredProficiency in basic computer troubleshooting Basic Qualifications Bachelor Degree in Nursing with a compact Registered Nurse (RN) license, or multistate LMSW, requiredOne (1) year hospital clinical experience, requiredOne (1) year hospital discharge planning experience, required Options Apply for this job onlineApplyShareRefer this job to a friendRefer Sorry the Share function is not working properly at this moment. Please refresh the page and try again later. Share on your newsfeed Need help finding the right job? We can recommend jobs specifically for you! Click here to get started. Application FAQsSoftware Powered by iCIMS
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