Transitional Care Manager

Job description

Job Summary This role is a member of the integrated community care team (ICCT), providing in-person discharge planning, care coordination and integrated case management supports for members currently admitted at an inpatient facility. The transitional care manager (TCM) is assigned acute and post-acute facilities in the community. TCMs are assigned to the members at the time of admission and care coordinate for their complex medical, behavioral, and social determinants of health needs. Working in partnership with the inpatient facility and the health plan, the TCM coordinates care in collaboration with AbsoluteCare Medical Director and primary care providers, community primary care providers and specialists and local community resource and service agencies required to meet the member’s individual post discharge needs. TCM effectiveness is measured by value-based care outcomes including admission and readmission rates, length of stay, bed days and hospital follow-up completion rates. Duties and Responsibilities: - Meet with members during their inpatient admission and develop a person-centered care plan (PCCP) to address their discharge and care transition needs. - Call members post...