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Summary: Transitional Care Manager

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TITLE: Transitional Care Manager ID #: ??

DEPARTMENT: Case Management FLSA:

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This description is intended to describe the general nature and level of work being performed by people assigned to this classification. This is not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. Further, this description is not intended to limit or in any way modify the right of any supervisor to assign, direct and control the work of employees under his/her supervision. The position must demonstrate competencies for the following use group:

GENERAL SUMMARY:
Care Manager coordinates …show more content…

Engages and collaborates with patients, families, inpatient multi-disciplinary staff, the primary care provider, and the community in care planning, delivery of care, and discharge target populations during the transition period (normally 30 days post discharge.) Responsible for developing a comprehensive individualized plan of care and targeted interventions. Continually monitors patient/family response to plan of care, and revises the care plan as indicated.
2. Works with hospital case management team to identify the targeted high risk populations within the hospital utilizing risk stratification process and discharge lists. Implements clinical interventions and protocols based on risk stratification and evidence-based clinical …show more content…

Ensures a safe and smooth transition from hospital to patient’s primary care medical home by coordinating and overseeing the discharge process, identifying that all steps have been completed when hand off occurs.
4. Provides follow-up with patient/family when patient transitions from one setting to another. Completes timely post-hospital follow-up: Medication reconciliation, PCP or specialist follow-up appointment, assess symptoms, teach warning signs, review discharge instructions, coordination of care, and problem solve barriers.
5. Coordinates patient care through ongoing collaboration with PCP, patient/family, community, and other members of the health care team. Fosters a team approach and includes patient/family as active members of the team. Takes the lead in ensuring the continuity of care which extends beyond the practice boundaries. Manages the TCM Billing Program. Serves as liaison to acute care hospitals and post acute care services.
6. Excellent assessment skills: Displays excellent assessment experience and skills by utilizing evidence based practice knowledge and skilled intervention based on chronic disease models in order to effectively prioritize and complete comprehensive assessments and facilitate appropriate care coordination.
7. Performs other duties as

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