Transition of Care Coordinator RN

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Requirements

• Ensures safe and appropriate transition between settings by collaborating with identified points of contact at facilities, members, responsible parties, legal guardians, providers, and support networks through the interdisciplinary care team process.
• Analyzes utilization, self-reported, and clinical data available to consolidate information and begins to identify comprehensive member needs.
• Coordinates care and reassesses member’s needs as clinically indicated and per desktop and jobaid requirements
• Educates and supports member/caregiver focusing on the seven primary areas: medication management, use of personal health record, follow up care, signs and symptoms of worsening condition, nutrition, functional needs and advance directives.
• Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and address complex clinical indicators which impact care planning and resolution of member issues.
• Provides crisis follow up to members to help ensure they are receiving the appropriate treatment/services.
• Applies and/or interprets applicable criteria and clinical guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member’s needs to ensure appropriate administration of benefits.
• Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and promotes lifestyle/behavior changes to achieve optimum level of health.
• Develops and monitors established plans of care to meet the member’s goals.
• Utilizes case management, utilization management, and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.

Benefits

• Medical, dental, and vision coverage
• Paid time off
• Retirement savings options
• Wellness programs
• Other resources