Transitional Care Manager RN Triage

Yale New Haven Health•New Haven, CT

1d•Remote

About The Position

The Transitional Care Manager Triage RN is part of the Enterprise Office of Population Health's Ambulatory Care Management team and is accountable for improving health outcomes for managed populations. The role provides clinical triage, post-discharge follow-up, and care coordination to support safe transitions of care and reduce avoidable Emergency Department visits and readmissions. The nurse uses evidence-based guidelines and communication skills to assess patient needs, manage symptoms, provide education, and escalate care appropriately. The role collaborates with providers, care management teams, and community resources to guide patients to appropriate care, address access barriers, and ensure timely follow-up. Duties include post-hospital and post-ED outreach, medication and discharge plan review, referral coordination, EHR documentation, report generation, and adherence to quality, productivity, and patient experience standards. The role requires independent clinical judgment, flexibility in managing priorities, strict confidentiality, and a commitment to service excellence. It also supports quality improvement, maintains knowledge of community resources, and coaches and supports triage staff and Health Advisors as assigned. The nurse works closely with RN Chronic Care Managers to enroll eligible patients who may benefit in Chronic Condition Management (CCM). This is primarily a remote position, with travel to onsite practice locations as requested by management. The role requires attendance at initial onsite orientation and onboarding and monthly onsite training. Outreach occurs seven days a week, requiring weekend and some holiday staffing.

Requirements

Bachelor's degree in a clinically related field.
R.N. license and RN licensure in Connecticut.
At least 3 years of clinical experience in direct patient care.
At least 2 years of case-management experience in an acute, community, or post-acute provider or health plan.
Motivational interviewing skills.
Ability to work in an iterative care environment responsive to evolving patient and institutional needs.
Excellent verbal and written communication skills.
Excellent organizational skills and ability to manage multiple priorities.
Ability to work independently with minimal supervision.
Ability to function as an integral team member and flexibility in sharing responsibilities.
Working knowledge of computers and basic software applications used in job functions, such as word processing, databases, and spreadsheets.
Ability to attend onsite orientation and onboarding and monthly onsite training, and travel to practice locations as requested.
Ability to support outreach seven days a week, including weekend and some holiday staffing.

Nice To Haves

Validated translation capability.

Responsibilities

Perform post-hospital discharge and post-ED visit calls to identify and address issues that could lead to readmission or an unnecessary Emergency Department visit.
Conduct post-discharge follow-up interviews, assess barriers to health equity, and help manage barriers or refer patients to community resources, including transportation assistance.
Engage patients and caregivers to confirm understanding of post-acute discharge plans, review discharge instructions and medications, and ensure follow-up appointments are scheduled and can be attended.
Route or refer patients appropriately and connect them with available services and resources, including connected services when appropriate.
Generate and manipulate daily EHR reports using appropriate filters, including discharge reports.
Guide patients to the clinically appropriate and cost-effective level of care.
Provide educational tools and educate patients and families about safe discharge, readmission prevention, disease management, and wellness.
Collaborate with the multidisciplinary healthcare team to evaluate and redirect care plans and streamline service delivery.
Coordinate with referral agencies to arrange ordered equipment and related services when appropriate and as directed by the Care Management team.
Use independent judgment to prioritize work and use time efficiently; communicate professionally and provide positive customer service, including under pressure.
Apply evidence-based practices and clinical guidelines to care plans and patient interventions, and meet care-management quality standards for case opening, documentation, actionable care plans, and timely case closure.
Develop knowledge of population health, health equity, value-based care, managed-care trends, payer regulations, reimbursement, and utilization.
Perform telephonic triage using best-practice clinical protocols and, when indicated, standing orders or referral trees to direct patients to the appropriate level of care.
Collaborate with clinicians and other resources to obtain timely responses and, when applicable, resolve issues in one call.
Follow up with patients regarding test results, education, escalation, or symptom management triage as appropriate.
Adapt flexibly to changing situations and reprioritize work as needed.
Maintain patient confidentiality and working knowledge of regional community resources, including urgent care, walk-in care, video care, and Emergency Departments.
Obtain requested clinical documentation.
Coach, train, and mentor new and existing triage staff; provide routine feedback and oversight to Health Advisors.
Perform other duties as requested or required.
Work remotely in accordance with organizational remote-worksite standards and travel to onsite practices, orientation, onboarding, and monthly training when required; support outreach seven days a week, including weekends and some holidays.