Transitional Care Manager Position Available In New York, New York

Transitional Care Manager Community Healthcare Network Inc – 4.3 New York, NY Job Details $61,777.80 – $69,500.40 a year 3 hours ago Benefits Health insurance Dental insurance Vision insurance Retirement plan Qualifications Bilingual Spanish CPR Certification Nursing Microsoft Excel Management RN License Primary care English Mid-level Supervising experience Bachelor of Science in Nursing Discharge planning Care plans Nursing Full Job Description

WHO WE ARE

Community Healthcare Network (CHN) is a not-for-profit organization providing more than 65,000 New Yorkers with primary and behavioral healthcare, dental, nutrition, wellness, and needed support services. Our network is made up of 14 federally qualified health centers throughout Brooklyn, the Bronx, Queens, and Manhattan, along with a fleet of mobile vans that bring health services to underserved people in need throughout New York City. We provide judgment-free, high-quality healthcare, without regard to race, religion, orientation, gender identity, immigration status or ability to pay. We turn no one away.

WHAT WE OFFER

Growth and development: Access to various healthcare professionals and benefits to deepen understanding and interest in the various disciplines involved in community health programming.

Supportive Team culture:

Be a part of an interdisciplinary environment where your ideas and work are valued and encouraged.

Comprehensive benefits:

Including health, dental and vision insurance, retirement plans, employee assistance programming and more.

POSITION SUMMARY

The Transitional Care Manager is responsible for managing a patient’s successful transition from hospital to home and is accountable for developing, implementing, and evaluating comprehensive transitional care interventions. They are responsible for managing the post-acute care of high-risk patients who are at risk for poor health outcomes, frequent emergency room visits, and hospital readmissions and working with complex and varied patients and situations. The position’s primary assignment will be remote.

DUTIES AND RESPONSIBILITIES

Extract data from internal and external data platforms to compile patient outreach lists, as directed. Conduct outreach to patients using multiple modes of communication, i.e., telephone, texting, video prior to and post-discharge from the hospital to provide support with discharge planning and care coordination. Provide short-term transitional care management post-discharge, including medication reconciliation, review of hospital discharge instructions, identification and rectifying gaps in care, coordination of post-discharge appointments and services (durable medical equipment, home health), and coordination of care across the care continuum. Initiates and maintains communication and collaboration with physicians, social workers, care team leaders, staff nurses, other care giving disciplines, and patients/families to develop, implement, and evaluate a transition plan of care for each patient. Monitors the achievement of clinical outcomes and communicates with patient care teams. Advocates for patients and families within the health care system, with community providers and across the continuum of care. Provides direct supervision and leadership support of population health staff. Develops, implements, and evaluates comprehensive patient education programs. Maintain care records including documentation of outreach and visit notes, assessments, care plans, care conferences, relevant external patient records, and release of information forms. Obtain external patient records via electronic health records systems, secure email, or fax and upload the records into the patient’s chart, assigning them to the appropriate parties. Review individual clinical records for presence of adequate and required documentation, using chart review tools. Supports Transitional Care leadership with system-level quality improvement. Participates in clinical performance improvement activities to achieve set goals. Periodically submits reports to the Director of Quality/Healthcare Innovation as needed. Participate in Population Health team meetings and supervision, as assigned. Performs other related duties, as assigned.

EDUCATION & EXPERIENCE REQUIRED

Nursing Degree from an accredited institution, BSN preferred. Currently registered to practice as a Registered Nurse in New York State. Current CPR certificate or plan to attend a CPR training course within six (6) months of employment. Minimum of three (3) years of clinical nursing experience in a primary care or community health setting, preferably a FQHC. Bilingual preferred (English/Spanish). One (1) year in a supervisory or management role preferred.

KNOWLEDGE, SKILLS AND ABILITIES REQUIRED

Demonstrated commitment to continuing professional development. Interest and knowledge of current practices in the broad field of primary care. Ability to relate comfortably and professionally to all clients/patients in discussing their needs for health education. Ability to work both independently and cooperatively to meet the objectives of the program. Demonstrated proficiency with Microsoft Excel. Ability to multi-task under pressure. Ability to evaluate patients in the context of their community. Ability to work collaboratively and independently on assignments and projects. Strong interpersonal skills.