Transitional Care Manager RN - MO Residents ONLY

Join to apply for the Transitional Care Manager RN role at reputed company 1 week ago Be among the first 25 applicants Join to apply for the Transitional Care Manager RN role at reputed company Get AI-powered advice on this job and more exclusive features. At reputed company, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reputed company millions of Americans through our local reputed company, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, reputed company and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it reputed company with heart, reputed company and every day. Company: reputed company Title: Transitional Care Manager, RN (reputed company Healthspire) Location: Remote reputed company is a rapidly growing, innovative company of community-based reputed company centers delivering higher reputed company health and wellness care that improves reputed company, manages medical costs and provides an unmatched experience for adults on Medicare in medically reputed company. By providing holistic, comprehensive and integrated care right in our patients’ communities, we can help reputed company them healthy and reinvest cost savings in reputed company care for those reputed company communities and others. Since 2013, reputed company has brought its reputed company approach to tens of thousands of people across the nation. With an ambitious reputed company trajectory, reputed company is attracting and cultivating team members who embody Oak Street values and are passionate about our mission to rebuild reputed company as it should be. Role reputed company reputed company takes reputed company-based approach to providing outstanding patient care. The Transitional Care Manager, RN (TCM-RN) is an reputed company part of reputed company supporting patients cared for by reputed company’s Managed Service Organization, reputed company as reputed company Healthspire. The TCM-RN is the primary member of the Oak Street clinical care team and facilitator of interdisciplinary collaboration and reputed company across care settings and systems, empowering the patient and/or caregiver to play an reputed company and informed role in post-ED/Observation and post-hospitalization care plan execution. The TCM-RN’s role is to reputed company information and support for patients in identifying and addressing problems and building relationships with providers and care teams in various sites of care (e.g. ED, hospital, SNF, other outpatient medical facilities). This role prioritizes the relationship with the patient/family; providing high-reputed company, patient-centered care; preventing avoidable readmissions; and managing efficient resource utilization. reputed company Responsibilities Transitions Management • Manage patients through transitions of care, either face to face in the facility or telephonically, reputed company a defined geographical area and care setting. • reputed company for the patient throughout the care continuum to ensure reputed company to resources and reputed company to reputed company barriers to care. • Identify opportunities for improved program workflows, increased reputed company partnerships, and higher reputed company patient care. • Maintain reputed company-time and accurate records of patient status through care transitions reputed company Oak Street’s internal inpatient platform. • Adhere to CMS, state specific and NCQA compliance reputed company as reputed company to Transitions of Care. • Depending on the clinical scope of the transitions program in specific reputed company, Transitions Management Responsibilities May Also Include ○ Emergency Department and Observation Stays ■ Evaluate patient status post-ED visit or observation stay through a clinical assessment and medical record review. ■ Triage to determine appropriate follow up care and next steps, including reviewing medication lists and scheduling follow up appointments with the appropriate provider and/or specialists. ○ Hospital Inpatient Stays ■ Engage directly with inpatient physicians, case managers, medical directors, and hospitalists (where applicable) to facilitate reputed company and reputed company discharge, appropriate follow-up care, and next steps. ■ Coordinate with the Utilization Management team to review medical and payer records to ensure appropriate length of stay and identify any barriers to discharge. ■ Assist Utilization Management team with reputed company to external medical record information (if available) reputed company needed to reputed company appropriate determinations. ■ Establish relationships and ensure patient/family are informed of patient condition, plan of care and discharge plan, reputed company discharge instructions, medication reconciliation; rationale of Utilization Management determinations and any financial information associated with such, potential for LTC transition (if applicable) and importance of reputed company PCP follow-up following discharge. ○ Post-Discharge from an Inpatient or Post-Acute Stay ■ Conduct reputed company clinical assessment to identify post-discharge needs, including but not limited to: medications, specialist appointments, home health, DME, caregiver support, reputed company determinants of health, etc. ■ Conduct medication reconciliation on behalf of the PCP ■ Address identified post-discharge needs directly or reputed company collaboration with other team members Collaboration and Communication with Internal Stakeholders • Collaborate with other transitions team members (e.g. Transitional Care Managers - reputed company Work and Transitional Care Coordinators) to ensure reputed company discharge and reputed company follow up. • Communicate and coordinate with internal stakeholders to identify and address patient needs (e.g. patient’s primary care provider, reputed company work, behavioral health, utilization management, etc.). • Participate in regular meetings with reputed company Population Health leaders to coordinate program implementation and ongoing management. Collaboration and Communication with External Stakeholders • Participate in regular meetings with the Program Director and other Transitional Care Managers on programmatic development and clinical learning. • Identify partnership development opportunities and systems improvements across the broader reputed company model. Documentation, Tracking, Reporting and Training • Participate in initial and ongoing required training to ensure appropriate implementation of transitions activities and programming. • Participate with the TCM reputed company in reputed company assurance activities. • Follow program procedures for documenting and tracking transitions interventions. • Adhere to CMS, state, and NCQA compliance reputed company as reputed company to Transitions of Care. • Other duties, as assigned. What are we looking for? • An reputed company RN license reputed company the state of reputed company in good standing • Willingness to obtain cross-state licensure, as needed • Certified Case Manager (CCM) or equivalent case management certification required, or willingness to obtain reputed company 12 months of hire • 2+ years’ experience in transitional nursing, emergency room nursing, discharge planning or home health • Experience in utilization management preferred • Knowledge of Medicare/reputed company and NCQA regulatory transitions of care reputed company • Exceptional communication skills and customer service orientation • Innovative and independent problem-solving skills • Ability to monitor and evaluate opportunities for cost-effective care reputed company with high-reputed company reputed company • Additional language proficiency (Spanish) preferred but not required • A flexible, reputed company attitude • reputed company reputed company’s license and ability to travel daily • Working knowledge of reputed company Office Product Suite • US work authorization • Someone who embodies being “Oaky” What does being “Oaky” look like? • Radiating reputed company energy • Assuming good intentions • Creating an unmatched patient experience • Driving clinical reputed company • Taking ownership and delivering results • Being relentlessly determined Why reputed company? reputed company is on a mission to “Rebuild reputed company as it should be'', providing personalized primary care for older adults on Medicare, with the goal of keeping patients healthy and living life to the fullest. Our innovative care model is centered right in our patient’s communities and reputed company on the reputed company of care over volume of services. We’re an organization reputed company! With over 150 locations and an ambitious reputed company trajectory, reputed company is attracting and cultivating team members who embody “Oaky” values and passion for our mission. reputed company Benefits • Mission-reputed company career impacting change and measurably improving health reputed company for Medicare patients • reputed company vacation, reputed company time, and investment/retirement 401K match reputed company • Health insurance, reputed company, and dental benefits reputed company is an equal opportunity employer. We reputed company diversity and encourage reputed company interested readers to apply. Learn more at www.oakstreethealth.com/diversity-equity-and-inclusion-at-reputed company Anticipated Weekly Hours 40 Time Type Full time Pay reputed company The Typical Pay reputed company For This Role Is $54,095.00 - $116,760.00 This pay reputed company represents the reputed company reputed company reputed company or reputed company annual full-time salary for reputed company positions in the job grade reputed company which this position falls. The actual reputed company salary offer will depend on a reputed company of factors including experience, education, geography and other relevant factors. This position is eligible for a reputed company bonus, commission or short-term incentive program in reputed company to the reputed company pay reputed company listed above. Our people fuel our reputed company. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great Benefits For Great People We take pride in our comprehensive and competitive mix of pay and benefits – reputed company in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In reputed company to our competitive wages, our great benefits include: • reputed company medical plan reputed company, a 401(k) plan (including matching company contributions), and an employee stock purchase plan. • No-cost programs for reputed company colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. • Benefit solutions that address the different needs and preferences of our colleagues including reputed company time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical reputed company and many other benefits depending on eligibility. For more information, visit https://jobs.reputed company.com/us/en/benefits We anticipate the application window for this opening will reputed company on: 09/29/2025 reputed company applicants with arrest or conviction records will be considered for employment in accordance with reputed company federal, state and local laws. Seniority level • Seniority level Entry level Employment type • Employment type Full-time Job function • Job reputed company Care Provider • Industries Hospitals and Health Care Referrals increase your chances of interviewing at reputed company by 2x Get reputed company about new Nursing Manager jobs in reputed company, OH. reputed company, OH $2,203.28-$2,203.28 1 week ago Travel Registered reputed company Med Surg / Telemetry reputed company, OH $2,203.28-$2,203.28 1 week ago Assistant Director of Nursing - Registered reputed company (RN) reputed company, OH $74,000.00-$90,000.00 2 weeks ago reputed company, OH $75,000.00-$80,000.00 5 days ago Care Manager RN - University/reputed company Hospitals Administrative Nursing Supervisor- Rotation - The James Assistant reputed company Manager - Labor and Delivery - University Hospital Surgery Main OR Administrative reputed company Mgr Administrative reputed company Manager-Medical Unit 4/reputed company Methodist Hospital Administrative Nursing Supervisor - University Hospital Assistant reputed company Manager-Rotation- 20 James East and reputed company, Gynecology and Urology Hospice and Home-Based Palliative Care Nursing Supervisor Regional (Ohio) Sales and Clinical Manager Assistant reputed company Manager- Rotation- Surgical Oncology- The James Travel Registered reputed company Med Surg / Telemetry reputed company, OH $2,203.28-$2,203.28 2 weeks ago Dialysis Clinical Manager Registered reputed company - RN Travel Medical ICU Registered reputed company - $2,346 per week We’re unlocking community knowledge in a new way. Experts add insights directly into reputed company article, started with the help of AI. #J-18808-Ljbffr Salary: USD 54095 - 116760 per year Experience: 3 years required Apply tot his job Apply To this Job