RN Care Managers - Transitional Care Management - FT Days - Innovation Care Partners
Posted on: September 9, 2020
HonorHealth is a non-profit, local community healthcare system
serving an area of 1.6 million people in the greater Phoenix area.
The network encompasses five acute-care hospitals, an extensive
medical group, outpatient surgery centers, a cancer care network,
clinical research, medical education, a foundation and community
services with approximately 12,300 employees, 3,700 affiliated
physicians and 3,100 volunteers.
HonorHealth was formed by a merger between Scottsdale Healthcare
and John C. Lincoln Health Network. HonorHealth's mission is to
improve the health and well-being of those we serve.
The Transitional Care Manager RN is an integral member of the care
management team, working with patients and their families to assure
a smooth transition following discharge from the hospital. This
position works collaboratively with the Chief Medical Officer,
providers, hospital based specialists, Care Coordinators and other
health care professionals/agencies to ensure a smooth transition
from the hospital to outpatient care that is coordinated across the
health care continuum.
- The Transitional Care Manager RN collaborates with
patients/caregivers early in the inpatient episode in preparation
for discharge. Key areas of focus include:
Establish relationship with patient/caregiver
Assure PCP is aware of patient's admission
Assess readmission risk and barriers to care outpatient including
home support, medication management, expectation, etc.
Coordinate with hospital case manager regarding discharge plans
Monitors and reviews cases that are in the emergency room;
facilitate the notification of network providers if patients
utilize the ER. Participate and support the ED Staff with the
patients most appropriate setting for care.
Provide effective communication of clinical information and plan of
care between the Hospitalist, Emergency Room Physician,
Specialists, and PCP; as well as other key healthcare providers
involved in the case.
Conduct effective post-hospitalization telephonic monitoring, or
depending on the tier level of each case and risk for
Review discharge instructions with patient including education
required due to new medications/changes to medication regimen,
disease specific "red flags" of complications
- The Transitional Care Manager will facilitate a smooth and
timely transition from acute care back to the appropriate primary
Coordinates follow-up care with PCP and practice Care Manager
/health coach(office based or centralized) regarding outpatient
follow-up appointment and plan of care
Communicates key information regarding inpatient stay and discharge
plans to patient's PCP/office care manager/health coach.
Assures effective transition and final hand-off to the patient's
PCP and his/her office based care manager/health coach.
Coordinate with (employee plan) or Payer Care Management regarding
- Facilitates and promotes a collaborative process and
communication between all health care team members, inclusive
patients/clients, families and significant others to ensure the
process of integrated care services are targeted, appropriate, and
beneficial to the population served from admission through the
- Communicate effectively and professionally using all modalities
i.e. technology, written letter, and verbal with both clinicians
and patients/caregivers in a way that is both clear and concise.
Assesses, determines, and evaluates appropriate disposition and
makes independent judgments based on critical thinking skills and
- Performs active listening, uses motivation interviewing and
open ended questioning techniques and guided care goal setting for
- Maintains all regulatory educational requirements participating
in continuing education and quality improvement activities.
Demonstrates professional behavior and promotes cooperation and
- Demonstrates technical skill and new forms of technology in
maintaining clear and professional clinical documentation in
software data base for cases followed under transition and for case
- Supports and participates in the development and maintenance of
Scorecard. Maintains accurate metric tracking for daily
- Maintains and manages to their caseload
- Performs other duties as assigned
Associate's Degree from an accredited NLN /CCNE institution in
2 years Registered Nurse (RN) Required
1 year as Case (or Care) Manager Required
Licenses and Certifications
Registered Nurse (RN) State And/Or Compact State Licensure
Basic Life Support (BLS) Required
Keywords: HonorHealth, Scottsdale , RN Care Managers - Transitional Care Management - FT Days - Innovation Care Partners, Healthcare , Scottsdale, Arizona
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