Transitions of Care - Program Care Manager (RN)

Stanford Health Care•Palo Alto, CA

5d•$89 - $118•Onsite

About The Position

The Transitions of Care (TOC) Patient Care Manager is a Registered Nurse who provides clinical and operational leadership and works in partnership with nursing, the multidisciplinary healthcare team, and hospital/system leaders to develop a quality practice setting that supports a high-quality, patient-centered transitional care model to improve outcomes. The TOC Nurse Manager is accountable for the effective delivery of safe, timely, and evidence‑based transitional care services for designated populations, ensuring patients experience coordinated, compassionate, and seamless transitions from hospital to home or post‑acute settings. This role oversees clinical operations, staff performance, and program outcomes for TOC services, with a strong focus on readmission prevention, post‑discharge safety, patient engagement, and continuity of care. Responsibilities include coordination of patient care; supervision of a professional team that includes multiple nursing and other staff as appropriate; coordination of transitional care workflows across settings; administrative and budget management; troubleshooting of problem areas including clinical and operational barriers that impact safe post-discharge care; organizational change management; ensuring compliance with accreditation and regulatory standards; quality assurance/quality improvement; safety and risk management requirements as well as actualization of hospital and unit policies, goals and objectives. Further, improving unit operations, enhancing communication and feedback, TOC programmatic development including standardizing of clinical practices, customizing education and staff roles, and accepting organizational accountability for services provided to recipients are critical outcomes expected of this role. The Nurse Manager role is critical to hospital operations and minimally accomplishes the following essential duties. Patient Care Manager I vs. II designation is based on span of control, hours of operation, and level of unit complexity.

Requirements

Bachelors and/or Masters in Nursing from an accredited college or university.
Three (3) years of progressively responsible and directly related work experience.
Ability to contribute to health care policy formulation when working in partnership with a multidisciplinary team of health care providers.
Ability to delegate responsibly to others, activities according to ability, level of preparation, the standards of practice and regulatory guidelines.
Ability to develop programs and lead process improvement projects.
Ability to establish the strategic direction and business plans for a functional group.
Ability to initiate and implement change conducive to the improvement of the quality and safety of patient care delivery.
Ability to provide leadership, influence others to meet patient needs and achieve shared goals, to effectively prioritize system resources to provide quality and valued patient care, promote cooperative behaviors, act as a role model, resource and mentor.
Ability to supervise, coach, mentor, train, and evaluate work results.
Ability to use information and keep abreast of developments in technology to communicate, manage knowledge, mitigate error, and support decision-making in patient care.
Knowledge of current theories, principles, practices, standards, emerging technologies, techniques and approaches in the nursing profession, and the health care system, and the responsibility and accountability for the outcome of practice.
Knowledge of laws, rules and regulations; standards and guidelines of certifying and accrediting bodies; hospital and department/unit standards, protocols, policies and procedures governing the provision of nursing care in the area of assignment.
Knowledge of principles and practices of organization, administration, fiscal and personnel management essential to the practice of nursing in the larger context of health care.
Knowledge of principles, practices and current trends in health care and hospital system organization and administration sufficient to provide clinical management, leadership, coordination, and operational direction for assigned areas of responsibility.
RN - Registered Nurse - State Licensure And/Or Compact State Licensure

Nice To Haves

Prior leadership experience preferred.
Program and/or project management experience preferred.

Responsibilities

Ensures the effective delivery of competent, compassionate, and efficient patient care by planning, organizing, and directing the nursing services of unit(s), including the assessment of patients, implementation of physicians' orders, treatment plans and medical procedures, administration of medication and record keeping of same as well as by monitoring and evaluating patient care processes and outcomes for the patient care unit(s); coordinates nursing activities with those of other services or disciplines.
Demonstrates clinical competency in assigned specialty area role models nursing practice consistent with the organizational and department mission, vision and values.
Communicates in a clear and effective manner to enhance team effectiveness, manage conflicts, engage employees and interdisciplinary colleagues in unit activities and performance changes.
Collaborates with others within the unit and with all hospital departments and disciplines to enhance problem solving, decision making and performance improvement.
Plans and forecasts the department budget by calculating required FTES, planning annual budgets, interpreting payroll and other key fiscal reports, projecting workload as well as monitoring and enhancing productivity.
Performs variance analysis by interpreting financial performance and identifying key drivers.
Identifies unit/capital budget needs in collaboration with physician and nursing colleagues.
Plans and implements staff scheduling, position controls and attendance control procedures.
Directs the personnel management of the employees assigned to the department consistent with state and federal labor laws, collective bargaining agreements, and nursing service and hospital philosophy, goals and policy.
Ensures that new staff is interviewed, hired, trained, oriented, precepted and evaluated.
Prepares and conducts employee performance appraisals.
Approves transfers, promotions and other decisions affecting employee pay and status.
Participates in initiating and documenting disciplinary actions and responding to grievances.
Assumes twenty four (24) hour responsibility and accountability for the operation of the assigned patient care unit(s), service(s), staff, and facilities.
Plans, organizes and directs short and long term departmental activities in accordance with hospital goals and accrediting organization standards.
Provides leadership and direction for the staff in the patient care unit(s) while supporting and actualizing the goals of the department, division, service, and hospital.
Functions as a resource to staff and interdisciplinary team members and interdepartmentally, consults on nursing care and professional nursing practice.
Assumes responsibility for accessing and utilizing appropriate date in order to monitor unit operations.
Accountable for achieving patient and staff satisfaction targets for the organization and unit of responsibility.
Develops, implements and evaluates process improvement projects/process in order to continually monitor and improve patient care.
Facilitates professional development and clinical growth of nursing staff through implementation and maintenance of unit specific competencies.
Promotes and facilitates educational opportunities based on assessment of staff needs.
Supports the quality framework, which includes both clinical and service quality indicators.
Creates an environment of patient care that is safe, effective, patient centered, timely, efficient and equitable.