Transitional Care Manager; RN or LVN

Transitional Care Manager (TCM) will work in office or field settings supporting our Clinicas del Camino Real membership. Performs care management duties to assess, plan and coordinate aspects of medical and supporting services across the continuum of care for post-discharge members, promoting quality and cost-effective care. Works with the care management and coordination teams to identify care transitions and transition support services.

• Transitional Care Manager (TCM) provides telephonic outreach to all patients that have been discharged from a hospital or Skilled Nursing Facility within 2 business days of discharge.
• TCM may also utilize other means of outreach communication such as Patient Portal, phone text, or letter as appropriate.
• The TCM provides patient assessment and support for treatment regimen adherence and medication management, education to patient and/or family members to support self-management and independent living and communicates with other members of the patient’s care team to ensure care coordination and safe transition back to community.
• The TCM schedules a face-to-face visit with the Primary Care Provider or Advanced Practitioner and assists with scheduling other specialists’ visits as indicated.
• The TCM identifies available community services and health resources and facilitates access to care and services available to patient/family when needed.
• TCM notifies PCP, via patient case or phone call, of any urgent patient needs.
• Accesses and navigates Health Plan or the hospital EMR systems to obtain daily patient discharge list or discharge notifications and patient medical record.
• Reviews hospital discharge list identifying those patients discharged to Skilled Nursing Facility/Rehab.
• Sends notification to SNFs of the CDCR patient admission and requests notification by SNF when patient is discharged.
• Performs patient outreach calls within the defined timeline (two call attempts within 2 business days) of hospital/SNF discharge.
• Performs telephonic assessment to assess member needs and collaborate with resources and provides education/support for treatment regimen adherence and medication management to support self-management and independent living.
• Identifies potential care gaps and makes referrals as appropriate.
• Identifies available community services and health resources and facilitates access to care and services available to patient/family when needed.
• Notifies Primary Care Provider/staff of any urgent needs or concerns.
• Schedules face-to-face visit with PCP/AP.
• Collects, documents, and maintains all member information and care management activities to ensure compliance with current state, federal, and third-party payer regulations.
• Makes referrals for Complex Case Management, Enhanced Case Management, or Basic Case Management.
• Provides feedback to leadership on opportunities to improve and enhance care and quality delivery for members in a cost-effective manner.
• Attends all required team/staff meetings.
• Performs other duties as assigned by people leader to meet business needs.

• Any of the following:
• Completion of accredited Registered Nurse (RN) program, or an accredited Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) Program.
• 1-3 years in case management, disease management, managed care or medical or behavioral health settings.
• A valid driver’s license with good driving record and be able to drive within applicable state or locality with reliable transportation.

• 3-5 years in case management, disease management, managed care or medical or behavioral health settings.
• Bilingual in Spanish and English preferred.
• Must have reliable transportation, as may be required to rotate to various Health Centers as needed.