RN Care Manager of Transition

The Registered Nurse (RN) Manager of Transition works alongside Strive care coordinators and nurse practitioners to coordinate and facilitate quality, cost-effective care while minimizing fragmentation of the healthcare delivery system for CKD and ESRD patients. The RN care manager will work specifically on Transition of Care Management efforts, to outreach patients who have been newly discharged from the in-patient setting within specified time requirements. The RN Care Manager will take every care management measure possible to help avoid patient complications and readmissions.

Essential Functions

• Identifies newly discharged patients and outreaches within 48 hours
• Assesses for immediate needs and identifies any signs and symptoms of potential complication
• Completes a comprehensive medication reconciliation
• Ensures patient understands all discharge instructions and newly prescribed medications
• Completes a full TCM Care Plan and ensures that it is shared with patient and patient’s entire care team
• Ensures that the patient has necessary follow-up visits scheduled with care team
• Collaborates with the care team to develop and or adjust the individualized and comprehensive care plan for the patient
• Identifies patient and/or clinic staff knowledge and understanding deficits regarding their specific program and situation. Provides the appropriate education, support and materials to facilitate informed decision making and understanding.
• Assesses patient conditions, in conjunction with the care team, such as the discovery of unreported medical and social conditions, or changes at home that may lead to adverse outcomes and ensures these concerns are referred to the appropriate sources for attention.
• Maintains and updates the appropriate program software to manage and record required information and data. Generates and analyzes reports as needed for management, identifying trends, anomalies and areas of concern.
• Adheres to company and clinical guidelines to identify, review, assess and allocate patients for program participation according to their identified needs
• Participates in process improvement activities.
• Collaborates with all levels of the clinical team to improve processes, communication, and team skills needed to provide the best care to our patients
• Utilizes clinical judgment, independent analysis, critical thinking skills, time management skills and detailed knowledge of case management program
• Participates in after hours on call program

Minimum Qualifications

• BSN or MSN degree from accredited school of nursing required.
• Current Registered Nurse (RN) license in the state of practice required.
• Minimum of 5 years’ experience in clinical nursing required.
• Current BLS certification
• Internet Connectivity - Min Speeds: 3.8Mbps/3.0Mbps (up/down): Latency <60 ms

Preferred Qualifications

• Skilled and passionate caring for patients with complex needs
• Demonstrated knowledge and understanding of data and managing to clinical, financial, and patient satisfaction outcomes.
• Demonstrated experience and effectiveness in change agent role.
• Excels at developing strong patient/family relationships that fosters engagement and best outcomes for all aspects of Strive Health’s Model of Care
• Basic computer skills and proficiency in MS Word and Outlook required

Annual Salary Range: $72,800.00-$96,050.00