Transitions Of Care Case Manager

Transitions of Care Case Manager Overview

• The Transitions of Care Case Manager coordinates discharge planning between hospitals, acute care facilities, and home settings, ensuring seamless transitions for patients.
• This hybrid role combines in-office and remote work, providing flexibility and a dynamic work environment.
• Collaborate with healthcare providers to ensure safe and effective patient discharges.
• Participate in case conferences, connecting members to medical providers and essential services.
• Engage in meaningful work that directly impacts patient outcomes and quality of care.
• Leverage your expertise in discharge planning and transitions of care to make a difference.

Transitions of Care Case Manager Key Responsibilities & Duties

• Coordinate hospitalizations, rehabilitation, and nursing home admissions, discharges, and tracking processes.
• Collaborate with care managers and providers during case conferences to develop effective care plans.
• Communicate with homecare teams to arrange setup and ongoing coverage for patients.
• Follow up on and address identified issues requiring immediate attention.
• Ensure accurate and timely documentation of all case management activities.
• Support patients and families during transitions, providing education and guidance as needed.

Transitions of Care Case Manager Job Requirements

• Associate of Applied Science (AAS) degree required, with a background in nursing preferred.
• Minimum of 2 years of experience in discharge planning and transitions of care.
• Strong knowledge of discharge planning processes and healthcare coordination.
• Proficiency in case management documentation and communication tools.
• Ability to work effectively in a hybrid work environment, balancing in-office and remote responsibilities.
• Excellent organizational and problem-solving skills to address patient needs promptly.