Transitional Case Manager- Christus Santa Rosa
About The Position
As the Transitional Case Manager (TCM) at Christus Santa Rosa, you will be facilitating seamless transitions for patients from facility settings to post-acute care. You will verify home health orders, assess care requirements, and ensure continuity of care. Your role includes assessing patients' health literacy, involving patients and families in care planning, and providing education to improve outcomes and promote self-management. You will implement rehospitalization reduction initiatives for patients at risk and communicate with healthcare providers throughout the transition.
Requirements
- Current, unrestricted RN, LPN, or SW licensure in state of practice
- 1+ years of home health experience or 1+ years of hospital case management experience
- Current driver's license, vehicle insurance, access to a dependable vehicle or public transportation
Nice To Haves
- Current CPR certification or ability to complete within 90 days of hire
Responsibilities
- Educate patients on post-discharge follow-up, homebound criteria, and obtaining prescriptions
- Assess readmission risk using the LACE tool
- Ensure patients and families have agency contact information
- Coordinate ancillary services (DME, Infusion) as needed
- Assist in preparing for patient care post-discharge
- Liaise between the agency and healthcare providers
- Communicate patient transfers and coordinate resumption of care
- Provide feedback on readmissions and non-admit decisions
- Perform other duties as assigned
Benefits
- a comprehensive benefits package
- incentive and recognition programs
- equity stock purchase
- 401k contribution
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
Number of Employees
5,001-10,000 employees
