Job Summary: The Care Manager-Registered Nurse (RN) Transitional Care Management (TCM) is an integral part of the healthcare team. Demonstrates comprehensive and advanced knowledge related to Transitional Care by helping guide patients to receive the care that they need to prevent frequent hospitalizations. Utilizes, discretion and independent judgement to complete a comprehensive assessment on each referral ensure they meet the program qualifications. Identifies services needed and begins to develop a complex plan of care. Facilitates the participants access to care and coordinates medical appointments, medication refills, therapy sessions, treatment programs, and need for transportation. Continually assessing and reassessing participant needs, and changing condition updates plan of care as changes occur. Conducts follow-up telephone calls, and periodic in-home visits to check on participants and family evaluating services and the need for more services. Reinforces health education on, medications, disease process, encourages them to be active participates in the care they are receiving. Identifies barriers and takes steps for resolution of issues with speed and sensitivity, seeks assistance when necessary. Meets regularly with physicians, pharmacists and multidisciplinary healthcare team, homecare agencies, long term care facilities about participants’ involvement in their care and progress towards a healthier life, ensures that the participants are getting the necessary services and identifies needs for additional services, and reviews and updates plan of care seeks input from team members for plan of care as needed. Works with healthcare teams, and agencies to strengthen the transitional care management program. Provides formal and informal education for community agencies, home care agencies, LTCF and the public about the TCM program. Maintains detailed information on each participant in case load, submits information as requested to leadership for review. Performs other duties as needed.

Education and Experience: Bachelor’s of Science degree in nursing (BSN). Minimum three years of experience in Care Management, Primary Care, or home care required. Experience working with older adults and families preferred.

Knowledge and Skills: Advanced knowledge of care and utilization management practices and methodologies. Knowledge of aging process, common health issues, and related psychosocial issues. Basic knowledge of healthcare regulations and accreditation required. Strong assessment, problem solving, interpersonal skills. Able to: read; write legibly; speak in English (and Spanish preferred) with professional quality; use computer and software programs necessary to the position; troubleshoot and calibrate patient care equipment. Able to relate and communicate positively, effectively, and professionally with others; be assertive and consistent in following and/or enforcing policies; work calmly and respond courteously when under pressure; lead, supervise, teach, and collaborate; accept direction. Able to communicate effectively in English in person, in writing, and on the telephone; think critically; work independently with minimal supervision; perform basic math functions; manage multiple assignments effectively; work well under pressure; problem solve; organize and prioritize workload; recall information with accuracy; pay close attention to detail. Able to distinguish colors and smells as necessary for patient care; hear sufficiently for general conversation in person and on the telephone; identify and distinguish various sounds associated with the work place/patient care; see adequately to read computer screens, medical records, and written documents necessary to position; discern temperature variances through touch. 

Licensures and Certifications: California Registered Nurse (RN) Licensure required. Basic Life Support (BLS) certification issued by the American Heart Association required. Public Health Nurse certification preferred.