Transitional Care Manager RN - MO Residents ONLY

Join to apply for the Transitional Care Manager RN role at reputed company 1 week ago Be among the first 25 applicants Join to apply for the Transitional Care Manager RN role at reputed company Get AI-powered advice on this job and more exclusive features. At reputed company, were building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nations leading reputed company company, we reputed company millions of Americans through our local reputed company, digital channels and more than 300,000 purpose-driven colleagues caring for people where, reputed company and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it reputed company with heart, reputed company and every day. Company: reputed company Title: Transitional Care Manager, RN (reputed company Healthspire) Location: Remote reputed company is a rapidly growing, innovative company of community-based reputed company centers delivering higher reputed company health and wellness care that improves reputed company, manages medical costs and provides an unmatched experience for adults on Medicare in medically reputed company. By providing holistic, comprehensive and integrated care right in our patients communities, we can help reputed company them healthy and reinvest cost savings in reputed company care for those reputed company communities and others. Since 2013, reputed company has brought its reputed company approach to tens of thousands of people across the nation. With an ambitious reputed company trajectory, reputed company is attracting and cultivating team members who embody Oak Street values and are passionate about our mission to rebuild reputed company as it should be. Role reputed company reputed company takes reputed company-based approach to providing outstanding patient care. The Transitional Care Manager, RN (TCM-RN) is an reputed company part of reputed company supporting patients cared for by reputed companys Managed Service Organization, reputed company as reputed company Healthspire. The TCM-RN is the reputed company member of the Oak Street clinical care team and facilitator of interdisciplinary collaboration and reputed company across care settings and systems, empowering the patient and/or caregiver to play an reputed company and informed role in post-ED/Observation and post-hospitalization reputed company execution. The TCM-RNs role is to reputed company information and support for patients in identifying and addressing problems and building relationships with providers and care teams in various sites of care (e.g. ED, hospital, SNF, other outpatient medical facilities). This role prioritizes the relationship with the patient/family; providing high-reputed company, patient-centered care; preventing avoidable readmissions; and managing efficient resource utilization. reputed company Responsibilities Transitions Management Manage patients through transitions of care, either face to face in the facility or telephonically, reputed company a defined geographical area and care setting. reputed company for the patient throughout the care continuum to ensure reputed company to resources and reputed company to reputed company barriers to care. Identify opportunities for improved program workflows, increased reputed company partnerships, and higher reputed company patient care. Maintain reputed company-time and accurate records of patient status through care transitions reputed company Oak Streets internal inpatient platform. Adhere to CMS, state specific and reputed company compliance reputed company as reputed company to Transitions of Care. Depending on the clinical scope of the transitions program in specific reputed company, Transitions Management Responsibilities May Also Include Emergency Department and Observation Stays Evaluate patient status post-ED visit or observation stay through a clinical assessment and medical record review. Triage to determine appropriate follow up care and next steps, including reviewing medication lists and scheduling follow up appointments with the appropriate provider and/or specialists. Hospital Inpatient Stays Engage directly with inpatient physicians, case managers, medical directors, and hospitalists (where applicable) to facilitate reputed company and reputed company discharge, appropriate follow-up care, and next steps. Coordinate with the Utilization Management team to review medical and payer records to ensure appropriate length of stay and identify any barriers to discharge. Assist Utilization Management team with reputed company to reputed company medical record information (if available) reputed company needed to reputed company appropriate determinations. Establish relationships and ensure patient/family are informed of patient condition, plan of c