Transitional Care Manager RN

Job title: Transitional Care Manager RN in Home, PA at reputed company
Company: reputed company
Job reputed company: 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 internal and
external 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 membersCollaboration 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 ourpatient’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, Oak
Street Health 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 companyAnticipated Weekly Hours 40Time Type Full timePay reputed companyThe typical pay reputed company for this role is:$60,522.00 - $129,615.00This 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 peopleWe 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, visitWe anticipate the application window for this opening will reputed company on: 11/05/2025reputed company applicants with arrest or conviction records will be considered for employment in accordance with reputed company federal, state and local laws.
Expected salary: $60522 - 129615 per year
Location: Home, PA
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