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 responsible and accountable for ensuring high quality patient care that is coordinated, efficient and supports desired clinical and financial outcomes. In collaboration with the healthcare team, the Transitional Care Manager utilizes evidence based practice to ensure that specific patient outcomes are achieved and that resources are appropriately used within designated fiscal time frames. The Transitional Care Manager participates in the ongoing evaluation of care delivery systems and practice patterns through identification of barriers to all aspects of care, including clinical, financial and community.
- 1. As part of the interdisciplinary health care team, coordinates and ensures the implementation of the plan of care, utilizing the principles of case management.
- 1.1 Establishes a system for coordinating the care of a patient throughout the continuum of care, linking the inpatient care with outpatient care, services and case management.
- 2. Ensures that an appropriate discharge plan is developed and implemented with the health care teams members to include:
- 2.1 Utilizing knowledge of internal and external resources to meet patient needs;
- 3. Facilitates movement along the continuum for patients within identified parameters
- 3.1 Ensure that the appropriate outside agencies are contacted and necessary referrals are initiated and followed through.
- 4. Along with other members of the health care team, acts as a patient advocate.
- 4.1 Exhibits awareness of ethical/legal issues concerning patient care and strives to manage situations to reduce risk.
Minimum of a Baccalaureate degree in clinically related field. R.N. required.
Minimum of five (5) years of relevant clinical experience.
RN Licensure in Connecticut
Case Management experience a plus. Motivational interviewing skills necessary.
Knowledge of discharge planning services and familiarity with utilization review practices. Excellent verbal and written communication skills. Excellent interpersonal communication skills with interdisciplinary team. Possesses excellent organizational skills and ability to handle multiple priorities. Ability to learn multiple computer systems. Ability to act in an independent role with minimal supervision. Flexible working together in a team and sharing responsibilities.