RN Transitional Care Manager - Remote

Registered Nurse Transitional Care Manager (RN- TCM)

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Turn your passion into your purpose.   

At Author Health, we are a new company offering technology-enabled health care services for seniors with mental health and other medical conditions. We are seeking a dedicated, compassionate and experienced Registered Nurse (RN) to join our healthcare team. The ideal candidate will have experience working with a highly diverse patient population including a geriatric population diagnosed with both chronic medical and behavioral health conditions. This candidate possesses the ability to manage a multitude of diagnoses while also effectively addressing health-related social needs (HRSN).

The RN- Transitional Care Manager (RN-TCM) will engage patients as part of the virtual care team model to identify medical risk factors, patient goals, appropriate interventions and implementation of the care plan. The RN-TCM will play a crucial role in achieving company goals of improving patient health outcomes, reducing avoidable emergency department and inpatient utilization and ensuring seamless trnsitions in care from facility to home to prevent readmissions. 

Performance in this care model utilizes continuous communication within the care team, either by phone, Slack or direct (telehealth) consultation.

WHAT IS YOUR SUPERPOWER?

Patient Assessment and Care Planning

• In collaboration with other care team members, including the patient and family/caregiver, the RN-TCM coordinates and implements the individualized plan of care for medically complex patients utilizing the nursing process. The RN-TCM will use their clinical judgment to determine the immediate medical interventions the patient will need in the home setting. The RN-TCM will evaluate the efficacy of interventions, adjusting and updating the care plan according to the review cycle, and/or when indicated, with the goal of reducing preventable ED/inpatient utilization and/or readmission.
• Monitor patient care plan goal progression including appointment adherence and avoidable ED/inpatient utilization, intervening as needed to eliminate medical and social barriers and close gaps in care to support appointment adherence and decrease avoidable ED/hospital visits
• Provide patient and caregiver education, empowering the patient with the knowledge to understand personally manage their own health conditions
• Identify caregiver burden and escalate to appropriate internal team to address
• Promote Author Health clinic appointment adherence to drive positive health outcomes
• Serve as a customer service champion proactively acknowledging and engaging the patient/caregiver and support their involvement in the care journey

Transitional Care Management 

• Initiate telephonic outreach for existing Author Health patients during hospitalization to coordinate with the hospital care team
• Initiate telephonic outreach to patients immediately post discharge to determine care based on diagnosis and immediate medical, social and environmental needs.
• Complete medication reconciliation with the patient based on discharge instructions
• Review the drivers of utilization (DOU’s) with the patient to initiate appropriate interventions and to collaborate with the patient to create, review or update a hospital avoidance plan (HAP).
• Provide health maintenance, and medication and disease management education to patients and families/caregivers

Care Team Communication

• Present patients during daily interdisciplinary team huddles to discuss complex physical health, behavioral health, and social needs, identify interventions and make recommendations for care, and facilitate connection of services 
• Collaborate across the continuum of care with external partners supporting physical health, behavioral health, and social needs to formulate care plan and partner together for best patient care and outcomes
• Facilitate connections between patients, caregivers, and community-based organizations, addressing health-related social needs (HRSN) with the support and collaboration of the care management team
• Collaborate with psychiatrists, nurse practitioners, licensed clinical social workers, and other care team members to deliver comprehensive patient care
• Effectively communicate, problem-solve, and maintain productive and effective interpersonal relationships while prioritizing the needs of the patient

Documentation

• Maintain timely and accurate patient/caregiver encounters and care coordination efforts in the electronic health record and relevant systems, accurately entering  billable time and appropriate CPT codes

WHAT WE ARE SEEKING:

Minimum Qualifications

• Authorization to work in the US
• Current and valid Registered Professional Nurse (RN) license
• Five (5) or more years as an RN, preferably in acute care setting; minimum three (3) years care management experience
• Knowledge of the RN professional scope of practice including its limitations
• Knowledge of differential diagnosis of complex medical diagnoses, common mental health and substance use disorders, health promotion, disease prevention, preventive services, and chronic diseases including physical, behavioral, social, and financial considerations

Skills and Experience

• Experience with geriatric populations
• Experience working with patients with complex/chronic medical conditions and co-occurring behavioral health diagnoses 
• Ability to multitask, utilize critical thinking and make sound decisions in critical situations
• Proven ability to work collaboratively in a team setting
• Possess strong relationship-building skills with patients and care team members
• Competence in engaging patients and caregivers through various communication methods, including computer, smartphone, and tablet applications relevant to the field
• Knowledge of how to appropriately address health-related social needs

Preferred Qualifications

• Bilingual in Spanish-English or Haitian Creole-English.

This role is fully remote. Physical requirements include the ability to use a computer. 

  WHAT WE OFFER:

• Retirement savings plan (401k) Plan up to 3.5% company match 
• Low cost benefits package for employee and dependents ( medical/ dental/ vision/ STD/ Life Insurance/ HSA/ FSA)
• Paid vacation
• Paid sick leave
• 9 paid holidays throughout the year with (2) additional flex holidays .. 11 in total! 
• Performance-based bonuses
• and more!

NEXT STEPS:

• Submit an application
• Upload an updated resume
• Share LinkedIn profile and/or cover letter

This behavioral health new company is committed to a diverse and inclusive workplace. It is the company’s policy to comply with all applicable equal employment opportunity laws by making all employment decisions without unlawful regard or consideration of any individual’s race, religion, ethnicity, color, sex, sexual orientation, gender identity or expressions, transgender status, sexual and other reproductive health decisions, marital status, age, national origin, genetic information, ancestry, citizenship, physical or mental disability, veteran or family status or any other basis protected by applicable national, federal, state, provincial or local law. The company’s policy prohibits unlawful discrimination based on any of these impermissible bases, as well as any bases or grounds protected by applicable law in each jurisdiction. If you need assistance or a reasonable accommodation during the application process because of a disability, it is available upon request. The company is pleased to provide such assistance and no applicant will be penalized as a result of such a request. In accordance with applicable legal requirements such as the San Francisco Fair Chance Ordinance Newco will consider for employment qualified applicants with arrest and conviction records.