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RN Case Manager
Job Location: Richmond, VA
The overall goal of the nurse transitional care manager position is to optimize the care of patients as they transition from acute, hospitalized care to lower levels of inpatient care and to home. Transitional care includes effective discharge planning, transfer of information at the time of discharge, patient assessment and education, and coordination of care and monitoring in the post-discharge period. The transitional care manager will assist with onsite care coordination, electronic medical record documentation, discharge planning, post discharge telephone calls with medication reconciliation, and primary care provider communication for patients admitted to high priority and high volume acute care facilities.
They will also serve as an advocate for the patient during and after their stay. She/he will coordinate/communicate with the patient and family, physician(s), hospital and insurer case managers, and community resources that provide services the patient may need, such as rehabilitation facilities, skilled nursing facilities, home health agencies or providers of medical equipment. In conjunction with the physician transitional care director, the transitional care manager will also assist with identification of high risk patients and subsequent intensified transitional care for these patients, including home visits, needs assessments, ongoing care coordination, participation in multidisciplinary case conferences, and communication with primary care providers.
The transitional care manager will adhere to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance, and policies and procedures. They will assist with building relationships with acute care facilities, hospitalists, and specialists. They will also serve as key liaisons to local medical directors and primary care providers.
What success will look like in 2 years:
Ideal candidate profile: