Full Job Description
At Memorial Hermann, we're about creating exceptional experiences for both our patients and our employees. Our goal is to provide opportunities for our diverse employee population that develop and grow careers in a team-oriented environment focused on patient care.
Every employee, at every level, begins their journey at Memorial Hermann learning about the history of the organization and its established culture built on trust and integrity. Our employees drive this culture, and we want you to be a part of it.
The Transitional Care Manager (TCM) is responsible for providing transitional care management services within the risk based payment programs. The TCM will manage and support an assigned population with moderate to complex care needs throughout a 90-day episode of care with the purpose of improving health outcomes and resource utilization through a coordinated approach. The TCM works in collaboration and continuous partnership with patients and their family members, as well as clinic, hospital and post-acute partners, along with community resources, to achieve the desired outcomes. The TCM will use a defined process to identify patients/members that are in a bundled payment model, establish care plans and goals, and coordinate care and services throughout the continuum of care. The goal of the TCM is to enhance patient health and well-being, improve adherence to established care plans, and ensure appropriate utilization of resources.
The TCM must be highly collaborative with strong customer service skills and demonstrate the ability to actively engage patients in positive relationships. The TCM is knowledgeable and experienced applying the skills necessary to provide care management services appropriate to the patient/member being served. The TCM demonstrates knowledge of the principles of growth and development as it relates to the different life cycles. Specific age groups that are served by this position are circled.
Education: Graduate of an accredited school of professional nursing required, BSN preferredor graduate of an accredited masters of social work program (MSW)
Current and valid license to practice as a Registered Nurse (RN) in the State of Texasor current and valid license as a Licensed Master Social Worker (LMSW) or Licensed Clinical Social Worker (LCSW) in the State of Texas required
Certification in case management (CCM or ACM) or other area related to chronic disease management or population health preferred, such as CCP, CPUR or CCTM
Experience / Knowledge / Skills:
Three (3) years of relevant clinical experience required, with at least two (2) years of experience in a care coordination and planning role with complex populations
Experience working in interdisciplinary teams
Excellent computer skills
Excellent communication and interpersonal skills
Demonstrates commitment to the Partners-in-Caring process by integrating our culture in all internal and external customer interactions; delivers on our brand promise of "we advance health" through innovation, accountability, empowerment, collaboration, compassion and results while ensuring One Memorial Hermann.
Manages and supports an assigned population with moderate to complex care needs throughout a 90-day episode of care.
Navigates patients through the care continuum with the goal of preventing readmissions and ensuring that care is provided at the right time, place, person and location.
Development of a patient-centered, holistic plan of care through the use of disease-specific pathways tailored to eliminate barriers to care and meet treatment plan goals. Collaborates with treatment teams to coordinate safe and efficient discharges to the appropriate preferred network.
Serves as a key member of the multi-disciplinary team, facilitating referrals to other interdisciplinary team members such as social workers, community health workers, pharmacy, behavioral health and health coaches in order to provide ongoing care coordination.
Increases continuity of care by building and facilitating effective and collaborative relationships with post-acute providers, physicians, and community resources. Provides Care Management services to assigned patients face-to face and telephonically. Travels to provider offices, patient homes and post-acute settings may occasionally be required.
Engages and coordinates with the patient and/or patient's designated family/caregivers to help resolve barriers to care.
Advocates for patients to receive relevant and appropriate community resources.
Manages effective transitions in care by facilitating warm hand-offs with the interdisciplinary team, physicians, and partners in the community.
Promotes and coordinates timely access to appropriate care, including discharge follow up appointments.
Facilitates effective and efficient utilization of clinical resources.
Increases comprehension and health literacy through appropriate education that is tailored to the patient's preferred learning methods.
Provides education and coaching regarding chronic disease/s, self-management, community resources, etc. to support and empower patients to take a more active role in managing their health, well-being and shared decision-making.
Coordinates warm hand-off to member's primary care provider upon successful completion of the program.
Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.
Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.
Other duties as assigned.