Transitional Care Manager RN

Performs assessment, treatment planning, intervention, monitoring, evaluation and documentation on identified High Risk members. Assesses and develops a care plan in collaboration with the admitting, attending and consulting physician, the member and other health care practitioners. Effectively assesses members to ensure provision and transition to an appropriate level of care, to minimize inpatient re-admissions, and to ensure that members’ medical, environmental and psychosocial needs are met across the continuum of care.

What you will need:

• Graduation from an accredited BSN Program.
• Current Michigan RN license,
• BLS certification
• Valid Michigan Driver’s license
• Three years acute care or case management experience
• Preferred: Two years of utilization or HMO experience.

What you will do:

• Keeps member/family members or other customers informed and requests further assistance when needed
• Functions as liaison between administration, members, physicians and other healthcare providers
• Performs a Health Risk Assessment (HRA) of the member and determines an acuity score for necessary scheduled follow-up
• Develops an outcome-based plan of care, based on the member’s input and assessed member needs. Implements and evaluates the plan of care as often as needed as evidenced by documentation in the member’s case file.
• Documents member assessment and reassessment, member care plans, and other pertinent information completed in the member’s medical record in accordance with Trinity Health Alliance of MI charting methodology, nursing standards, and company policies and procedures.
• Initiates onsite hospital visits/rounds as needed to assess patient progress and meet with appropriate members of the patient care team.

What you will work:

• Full time
• 40 hours per week
• Day Shift