Transitions Care Manager, Integra

Job description

Job Summary: The Integra Transitions NCM collaborates with the hospitals and skilled nursing facilities to pursue cost-effective, quality focused management interventions by achieving predetermined financial and clinical outcomes. Responsible for collaboration with the Integra Nurse Care Managers/Transition Managers (hospital and skilled nursing facility based) concerning quality initiatives, outcomes, etc. Responsible for providing ongoing communication with patients, continuing care coordinators, social workers, and physicians to ensure patients have appropriate resources/support in the Hospital and SNF setting and upon discharge to the community and intervening when patients are unable to be managed adequately. Tracks patients along with continuum of care, identifying patterns that have a negative cost-quality impact and assists with the development of plans for improving care. Duties and Responsibilities: Applies Case Management principles to the Hospital inpatient and Skilled Nursing Facility (SNF)-patient population to ensure appropriate utilization of resources and level of care. This includes assessing, planning, implementing, coordinating, evaluating, and collaborating wit...