Transitional Care/Clinic Liaison Manager

Central Neighborhood Hlth Fdn•Santa Fe Springs, CA

9h•Hybrid

About The Position

Central Neighborhood Health Foundation is a Federally Qualified Healthcare Center (FQHC) committed to the Triple Aim as described by the Institute for Healthcare Improvement. Improving the US health care system requires simultaneous pursuit of three aims: 1) improving the experience of care, 2) improving the health of populations, and 3) reducing per capita costs of health care. Preconditions for this include the enrollment of an identified population, a commitment to universality for its members, and the existence of an organization (an "integrator") that accepts responsibility for all three aims for that population. The Transition Care Manager will manage the Transitional Care Coordinator (TCC) staff and the Clinic Liaison Staff. Will serve as the key point of contact for onsite staff and PIH/Pipeline Hospital networks. Oversee the coordination of post-acute care needs and other health system resources. Serve as a resource to the TCC staff and collaborate with all clinic departments to ensure the successful transition of the patients from the hospital and back to the PCP to manage their chronic illness. The practice of this position has a direct impact on patient outcomes and CNHF performance measures. The Transitional Care Manager utilizes data to provide training and feedback to the Clinic Liaisons and TCC staff. Manage the day-to-day operations of both programs including planning, assigning and direct work. Participate in hospital network meetings, regular staff meetings and organization department meetings. Implementation protocols, evaluation tools, and participate in ongoing quality improvement activities. Collects program data that indicates potential areas for system-wide improvement and for monthly reporting to the hospital networks.

Requirements

Minimum two years of management experience and knowledge of hospital networks.
Experience with care coordination and ED transitional care management.
California driver’s license and current auto insurance.
Excellent interpersonal communication, problem-solving, customer service and conflict resolution skills.
Excellent organizational skills and attention to detail.
Excellent time management skills with a proven ability to meet deadlines.
Computer skills in word processing, database management, and spreadsheets.
Ability to travel to clinics within Los Angeles, Riverside and San Bernardino Counties.
Maintains patient, employee, and Foundation confidentiality at all times, discussing patient or employee business only with appropriate parties who have a bona fide need to know; and communicating only the minimum amount of information necessary with respect to protected health information (PHI) as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Responsibilities

Ensure staff contact patient and care giver within 48 hours after discharge to schedule an appointment with the Primary Care Provider (PCP) and review and reinforce the discharge care plan.
Ensure proper documentation of Transition of Care Management (TCM) in EHR.
Oversee the TCC/Clinic Liaison staff provide post-discharge care coordination – including scheduling and ensuring completion of follow-up visit with the primary care provider or specialist within seven days and referral to case manager and other resources as needed.
Manage multiple sites in multiple locations, travel to and from sites.
Serve as a key contact for the onsite hospital network administration staff.
Educate patient/caregiver about indications that the discharged patient’s condition is worsening and when/how to respond.
Train the PCP on how TCM documentation and follow-up.
Identify specific data needs as well as information/data sharing workflows to enhance transition care.
Collaborate with Health Information Exchange platforms such as LANES and Medex, Health plans, IPAs, and hospitals to receive faxed and electronic copies of hospital census data for their patients on a daily basis.
Access clinical information and discharge notes/plans and upload it into the EHR.
Report utilization data to clinics on an ongoing basis.
Document and track the discharge and transitional care activities and resources provided to each patient.
Consolidate data and prepare dashboards documenting process activities/outcomes monthly for review by quality team, hospital networks and senior management.
Evaluate causes of relevant readmissions (within 30 days) to determine if additional transition support is needed.
Monitor compliance with transition workflows.
Ensure that members have 24/7 access to clinical advice and support.
Coordinates and facilitates the daily activities of the TCC and Clinic Liaison staff. Collaborate with all members of the healthcare team, hospital networks, patients and external customers.
Participates in performance improvement activities to achieve set goals.
Applies advanced critical thinking and conflict resolution skills using creative approaches.
Participates in the orientation of new department staff. Provides learning opportunities for students in various health care disciplines as requested.
Supports agencies as requested through the Department of Quality Management.
Participates in research surrounding transitional care. Identifies recurring clinical practice issues and contributes to the development of specific plans to address identified issues.
Participate in activities that support the advancement of care transitions, case management, and discharge planning through literature review, professional organizations, research, committee participation, etc. Consistently uses new knowledge, technology, and research in practice.
Performs other duties as assigned.