Transitional Care Manager

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Overview

To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.

The Transitional Care Manager is as a member of the Enterprise Office of Population Health's Ambulatory Care Management team and is accountable for improving the health outcomes of the populations being managed. The Transitional Care Manager works as part of a multi-disciplinary team under the direction of the Ambulatory Care Management leadership. The Transitional Care Manager is responsible for Transitions of Care (TOC) / Transitional Care Management (TCM) follow-up for patients transitioning between phases on the continuum of care, including but not limited to patient's post-hospital discharge.

The role includes performing post-hospital discharge calls, ED discharge follow-up calls, and post-acute transition calls, as applicable, and providing other transitional care support including ensuring timely follow-up appointments and logistics pertaining to obtaining medications. This role will work closely with RN Chronic Care Managers to enroll patients in Chronic Condition Management (CCM) if a patient is eligible and would benefit from the program.

EEO/AA/Disability/Veteran Responsibilities

• 1. Performs post-hospital discharge and post-ED visit phone calls. Works to reduce the readmission and unnecessary Emergency Department visits by proactively identifying and addressing potential issues that could result in return to an acute setting. 1. As part of the interdisciplinary health care team, the Care Navigation nurse performs post-discharge follow up interviews, assesses existing barriers to health equity and assists with management of barriers or referrals to community resources including facilitation of transportation needs.

  2. Engages patients and/or caregiver regarding care needs by validating awareness and understanding of post-acute discharge plan(s) including but not limited to review of discharge instructions, medications, and ensures scheduling and patient ability to attend follow-up appointments. 3. Facilitates appropriate routing or referrals and links patients to available resources and services needed, including use of connected services when appropriate 4. Generate and manipulate daily EHR reports to include various filters: i.e. discharge reports as recommended.

  5. Guides patients to the most clinically appropriate and cost effective level of care to address their clinical issues. 6. Provides educational tools to patients and/or community services as requested. Educates patients and families on all components of a safe discharge, and best practices to avoid readmissions, manage disease states, and attain optimal wellness.

• 2. Demonstrates an ability to serve as a collaborative member of a multidisciplinary healthcare team. 1. Assists care management team to evaluate and redirect the current patient plan of care in order to streamline the delivery of service. 2. Contacts and coordinates with referral agencies to arrange provision of ordered equipment and associated services when appropriate and as directed by Care Management team.

  3. Able to relate and communicate positively, effectively, and professionally with others; able to demonstrate positive customer service skills; work calmly and respond courteously when under pressure 4. Uses independent judgement prioritizes appropriately to ensure efficient utilization of time.

• 3. Demonstrates an understanding of clinical standards, quality performance goals and expected outcomes. 1. Demonstrates application of evidence-based practice and clinical practice guidelines to care plans and patient interventions. 2. Adheres to quality standards for care management per policy, including appropriate cases opened, comprehensive documentation, actionable care plans, and appropriate cases closed in a timely fashion.

  3. Develops knowledge of population health, health equity, value-based care concepts and their application to the goals and objectives of the role and the department. 4. Demonstrates an understanding of managed care trends, payer regulations, reimbursement, and the effect of utilization on the different methods of reimbursement.

• 4. Performs other duties as required or requested.

Qualifications

EDUCATION

Minimum of a Baccalaureate degree in clinically related field. R.N. required.

EXPERIENCE

Minimum of 3 years of clinical experience in direct patient care, 2 years of case management experience in an acute, community, or post-acute provider or health plan.

LICENSURE

RN Licensure in Connecticut

SPECIAL SKILLS

• Motivational interviewing skills necessary.
• Receptivity to working in an iterative care environment based upon evolving patient and institutional needs
• Excellent verbal and written communication skills.
• Possesses excellent organizational skills and ability to handle multiple priorities.
• Ability to work in an independent role with minimal supervision.
• Functions as an integral team member and demonstrates flexibility in sharing responsibilities.
• Validated translation capability preferred.
• Working knowledge of computers and basic software applications used in job functions, such as word processing, databases, spreadsheets, and others as needed.

PHYSICAL DEMAND

-Role is primarily a remote work position with the ability and expectation to travel to onsite practice locations from time to time as requested by management. Ability to attend initial onsite orientation and onboarding program as well as monthly onsite training obligations. Adheres to all organizational remote worksite standards. Outreach performed 7 days a week and requires weekend and some holiday staffing.

YNHHS Requisition ID

151377

How to Submit an Application:

After reading and knowing the criteria and minimum requirements for qualifications that have been explained from the Transitional Care Manager job info - YALE NEW HAVEN HEALTH New Haven, CT above, thus jobseekers who feel they have not met the requirements including education, age, etc. and really feel interested in the latest job vacancies Transitional Care Manager job info - YALE NEW HAVEN HEALTH New Haven, CT in 2025-06-25 above, should as soon as possible complete and compile a job application file such as a job application letter, CV or curriculum vitae, FC diploma and transcripts and other supplements as described above, in order to register and take part in the admission selection for new employees in the company referred to, sent via form this bottom.