TRANSITIONAL CARE MANAGEMENT (TCM), RN

Oneida Health•Oneida, NY

2d•$30 - $37•Onsite

About The Position

The Transitional Care Management (TCM) RN supports patients transitioning from an inpatient or observation stay to home and resuming care with their Primary Care Provider (PCP) and/or other outpatient providers. Using internal systems and the Regional Health Information Organization (RHIO), HealtheConnections, the TCM Coordinator identifies eligible patients and ensures each has a safe, timely, and appropriate follow-up care plan tailored to individual needs.

Requirements

Associate of Nursing degree.
New York RN certification.
Two years of nursing experience.

Nice To Haves

Bachelor’s of Nursing degree.
BLS certification.
One year of experience in a medical office environment.

Responsibilities

Access internal reporting and the RHIO each business day, Monday through Friday, to identify established patients recently discharged from an inpatient or observation stay.
Ensure a discharge summary is received in the patient’s Medent record for all discharges.
Alert practice staff about transitions of care for patients ineligible for TCM services by placing a triage document in the patient’s Medent record.
Identify and contact eligible patients by phone within two business days of discharge.
Document all patient contact and unsuccessful contact attempts in the Medent record using the TCM document.
Review all aspects of the TCM form with the patient and document pertinent patient information, medication reconciliation, barriers to care, patient care goals, and appropriate follow-up plans.
Schedule a TCM visit with the PCP within 7 to 14 days of discharge, based on patient need.
Provide ongoing follow-up assistance to patients for 30 days following discharge, as directed by the PCP.
Track TCM appointments until they are completed.
Ensure appropriate codes were applied and communicate with PCPs when coding needs to be modified to reflect the TCM visit.
Maintain the TCM visit tracking document.
Complete other duties as assigned.