Transition of Care Coordinator RN

CVS Health•Birdsboro, PA

5d•$60,522 - $129,615•Hybrid

About The Position

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Requirements

Minimum Associate’s or diploma nursing degree
3–5 years clinical practice experience (e.g., hospital, ambulatory care, or outpatient setting)
2+ years’ experience using a personal computer, including: Keyboard navigation, Navigating multiple systems and applications, MS Office Suite (Teams, Outlook, Word, Excel, etc.)
Strong customer service orientation and problem-solving skills
Excellent motivational interviewing skills and ability to build rapport and trust telephonically
Excellent documentation skills and adherence to compliance/regulatory standards
Highly organized and self-driven, able to work without direct supervision
Effective time management skills
Ability to achieve performance metrics
Strong technology proficiency
Flexibility with variable work schedules, including working 2 days weekly until 9pm local time
Ability to travel to surrounding counties

Nice To Haves

Case management and discharge planning experience in an integrated model
Bachelor’s and/or Master’s degree
CCM (Certified Case Manager) certification
Previous experience in Managed Care
Maternal and neonatal (Maternity/NICU) experience

Responsibilities

Ensures safe and appropriate transition between settings by collaborating with identified points of contact at facilities, members, responsible parties, legal guardians, providers, and support networks through the interdisciplinary care team process.
Through the use of clinical tools and information/data review, conducts assessments of referred member’s needs/eligibility and determines approach to meeting needs by evaluating available internal and external programs and services.
Analyzes utilization, self-reported, and clinical data available to consolidate information and begins to identify comprehensive member needs.
Follows members through their inpatient admission and continues oversight through transition from the acute setting to all other settings with the goal of reducing readmissions and increasing permanency in the community.
Available to conduct face-to-face visits as necessary for high-risk members.
Coordinate care and reassess member’s needs as clinically indicated and per desktop and jobaid requirements
Ensures members transition upon discharge with adequate supervision, recommended behavioral health, physical health, maternity health, pharmacy resources, and care management support.
Educates and supports member/caregiver focusing on the seven primary areas: medication management, use of personal health record, follow up care, signs and symptoms of worsening condition, nutrition, functional needs and advance directives.
Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and address complex clinical indicators which impact care planning and resolution of member issues.
Using advanced clinical skills, identifies crisis intervention with members experiencing a behavioral health, medical or maternity crisis and refers them to the appropriate clinical providers for thorough assessment and treatment, as clinically indicated.
Provides crisis follow up to members to help ensure they are receiving the appropriate treatment/services.
Applies and/or interprets applicable criteria and clinical guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member’s needs to ensure appropriate administration of benefits.
Using a holistic approach consults with managers, medical directors and/or other program representatives as needed to overcome barriers to meeting goals and objectives.
Presents cases at case conferences/rounds to obtain a multidisciplinary view in order to achieve optimal outcomes.
Engages and builds continued professional relationships at network facilities.
Identifies and escalates quality of care issues through established channels.
Communicates and collaborates with medical and behavioral health professionals to influence appropriate member care.
Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and promotes lifestyle/behavior changes to achieve optimum level of health.
Provides coaching, information, and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices.
Helps members actively and knowledgably participate with their provider in healthcare decision-making.
In collaboration with the member and their care team develops and monitors established plans of care to meet the member’s goals.
Utilizes case management, utilization management, and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.
Consistently meets defined performance and productivity standards
Ability to work two (2) evenings a week to 9pm
Other duties as assigned.