Position Overview The primary goal of the Transitions of Care (TOC) Care Manager is to provide care coordination services as members move from one setting to another. Examples of these settings include inpatient facilities, emergency department, rehabilitation facilities, long-term care facilities, and certified home health agencies. The goal is to prevent re-admissions and reduce avoidable admissions. This is accomplished through engagement and understanding of members' needs, environment, providers, support system and optimization of services available to them. In addition, ensuring follow up appointments are scheduled, conducting medication reconciliation, and providing education related to members' condition and necessary steps to remain safely in the community. The TOC Care Manager is expected to assess and evaluate member needs, be a creative, efficient and resourceful problem solver. In collaboration with the members' care team, a plan of care with individualized goals and interventions is updated, implemented and evaluated. Scope of Role and Responsabilities Provide care management support during transitions of care. Complete transitions of care assessment to identify member needs. Complete medication reconciliation. Address members' problems and needs: clinical, psychosocial, financial, environmental. Engage members in a collaborative relationship, empowering them to self-manage their physical, psychosocial and environmental needs. Prepare member-oriented plan of care with members, caregivers, and members of their care team, integrating concepts of cultural sensitivity and privacy practices. Ensure plans of care have individualized goals and interventions. Communicate plan of care with primary care physicians. Address gaps in care with the member and provider. Address members social determinants of health issues. Link members to available resources. Educate members and/or caregivers on relevant chronic diseases, preventive care, medication management (medication reconciliation and adherence), home safety, etc. Ensure access to care, reducing unnecessary hospitalizations, and appropriately referring to community support. Advocate for members by assisting them to address challenges and make informed choices regarding clinical status and treatment options. Conduct follows up calls as per transition of care protocols. Employ critical thinking and judgment when dealing with unplanned issues. Maintain knowledge of chronic conditions and use job aids as guidance. Ability to use data as a tool in tracking and trending outcomes and clinical information. Maintain accurate, comprehensive and current clinical and non-clinical documentation in the care management system. Comply with all orientation requirements, annual and other mandatory training courses, organizational and departmental policies and procedures, and actively participate in evaluation process. Maintain professional competencies as a care manager. Other duties assigned by Leadership Required Education, Training and Professional Experience Bachelor's Degree required. Minimum 2 years of care management experience in a healthcare setting or in a managed care organization. Ability to proficiently read and interpret medical records, claims data, pharmacy, lab reports and prescriptions required. Ability to work closely with members and caregivers. Ability to work collaboratively with various team members, interdepartmentally, and leadership. Licensure and/or Certification Required Valid New York State license and current registration to practice as a Registered Professional Nurse (RN) issued by the New York State Education Department (NYSED). Professional Competencies Integrity and Trust Customer Focus Functional/Technical skills Written/Oral Communication #MPH50 #LI-Hybrid