Care Manager-RN TCM

Loma Linda • Loma Linda, CA

10d • $60 - $80 • Hybrid

About The Position

The Care Manager-Registered Nurse (RN) Transitional Care Management (TCM) is an integral part of the healthcare team. Demonstrates comprehensive and advanced knowledge related to Transitional Care by helping guide patients to receive the care that they need to prevent frequent hospitalizations. Utilizes discretion and independent judgment to complete a comprehensive assessment on each referral ensure they meet the program qualifications. Identifies services needed and begins to develop a complex plan of care. Facilitates the participants access to care and coordinates medical appointments, medication refills, therapy sessions, treatment programs, and need for transportation. Continually assessing and reassessing participant needs, and changing condition updates plan of care as changes occur. Conducts follow-up telephone calls, and periodic in-home visits to check on participants and family evaluating services and the need for more services. Reinforces health education on medications, disease process, encourages them to be active participates in the care they are receiving. Identifies barriers and takes steps for resolution of issues with speed and sensitivity, seeks assistance when necessary. Meets regularly with physicians, pharmacists and multidisciplinary healthcare team, homecare agencies, long term care facilities about participants’ involvement in their care and progress towards a healthier life, ensures that the participants are getting the necessary services and identifies needs for additional services, and reviews and updates plan of care seeks input from team members for plan of care as needed. Works with healthcare teams, and agencies to strengthen the transitional care management program. Provides formal and informal education for community agencies, home care agencies, LTCF and the public about the TCM program. Maintains detailed information on each participant in case load, submits information as requested to leadership for review. Performs other duties as needed.

Requirements

• Bachelor’s of Science degree in nursing (BSN).
• Minimum three years of experience in Care Management, Primary Care, or home care required.
• Advanced knowledge of care and utilization management practices and methodologies.
• Knowledge of aging process, common health issues, and related psychosocial issues.
• Basic knowledge of healthcare regulations and accreditation required.
• Strong assessment, problem solving, and interpersonal skills.
• Able to read; write legibly; speak in English with professional quality.
• Able to use computer and software programs necessary to the position.
• Able to troubleshoot and calibrate patient care equipment.
• Able to relate and communicate positively, effectively, and professionally with others.
• Able to be assertive and consistent in following and/or enforcing policies.
• Able to work calmly and respond courteously when under pressure.
• Able to lead, supervise, teach, and collaborate.
• Able to accept direction.
• Able to communicate effectively in English in person, in writing, and on the telephone.
• Able to think critically.
• Able to work independently with minimal supervision.
• Able to perform basic math functions.
• Able to manage multiple assignments effectively.
• Able to work well under pressure.
• Able to problem solve.
• Able to organize and prioritize workload.
• Able to recall information with accuracy.
• Able to pay close attention to detail.
• Able to distinguish colors and smells as necessary for patient care.
• Able to hear sufficiently for general conversation in person and on the telephone.
• Able to identify and distinguish various sounds associated with the work place/patient care.
• Able to see adequately to read computer screens, medical records, and written documents necessary to position.
• Able to discern temperature variances through touch.
• California Registered Nurse (RN) Licensure required.
• Basic Life Support (BLS) certification issued by the American Heart Association required.

Nice To Haves

• Experience working with older adults and families preferred.
• Spanish preferred.
• Public Health Nurse certification preferred.

Responsibilities

• Utilize discretion and independent judgment to complete a comprehensive assessment on each referral to ensure they meet the program qualifications.
• Identify services needed and develop a complex plan of care.
• Facilitate participants' access to care and coordinate medical appointments, medication refills, therapy sessions, treatment programs, and need for transportation.
• Continuously assess and reassess participant needs and changing conditions, updating the plan of care as changes occur.
• Conduct follow-up telephone calls and periodic in-home visits to check on participants and families, evaluating services and the need for more services.
• Reinforce health education on medications and disease processes, encouraging active participation in care.
• Identify barriers and take steps for resolution of issues with speed and sensitivity, seeking assistance when necessary.
• Meet regularly with physicians, pharmacists, multidisciplinary healthcare teams, homecare agencies, and long-term care facilities regarding participants' involvement in their care and progress.
• Ensure participants are receiving necessary services and identify needs for additional services.
• Review and update the plan of care, seeking input from team members as needed.
• Work with healthcare teams and agencies to strengthen the transitional care management program.
• Provide formal and informal education for community agencies, home care agencies, LTCF, and the public about the TCM program.
• Maintain detailed information on each participant in the caseload.
• Submit information as requested to leadership for review.
• Perform other duties as needed.

Benefits

• Equal opportunities in all aspects of the employment process to every individual, regardless of gender, race, color, age, national origin, ancestry, physical or mental disability, marital or veteran status, genetic information or any other characteristic protected by law.
• Reasonable accommodations for otherwise qualified individuals requesting an accommodation due to a disability.
• Accommodation assistance with accessing job listings or completing an application, or during any other phase of employment.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level