Transitions RN Care Manager, Integra

Job description

Job Summary: The Integra Transition Manager collaborates with a group of Physicians to pursue cost-effective, quality focused management interventions by achieving a predetermined financial and clinical outcome. Responsible for providing ongoing communication with patients, continuing care coordinators, social workers, and physicians to ensure patients have appropriate resources/support in 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 acute care in-patient population to ensure appropriate utilization of resources and level of care. This includes assessing, planning, implementing, coordinating, evaluating and collaborating with the interdisciplinary team, patients, families and community providers. Assists in the facilitation of discharge planning for Integra ACO patients with Care Coordination who are in observation or admitted status from the acute care setting. This may include but is not limited to, acute re...