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RN Case Manager, Transition of Care (TOC) – PG County
R-1417 Job Description: PG County Cityblock’s Transition of Care (TOC) program helps members safely navigate their post-discharge journey from acute care and hospital settings back into the community. The TOC Registered Nurse Care Manager (RNCM) coordinates with hospital case managers to determine members’ needs and to complete discharge visits (in-home or virtual) with members and providers. The TOC RNCM will also be available for referrals to triage members’ needs and provide clinical education, with the goal of helping ensure that members do not return to the hospital. Responsibilities:
- Assign members and initiate outreach by contacting hospital case managers to understand each member's unique needs before engaging them in the TOC program.
- Complete self-efficacy and condition-specific screeners during the assess and intake phase, including behavioral health tools like PHQ-9, GAD-7, AUDIT, or DAST-10, to identify members requiring behavioral health programming.
- Conduct in-person clinical exams if appropriate and collaborate with care team members to determine if a different intensity program placement is needed.
- Participate in daily inpatient rounds while members are admitted, followed by post-discharge case conferences to support discharge planning.
- Collaborate with the TOC Care Coordinator and TOC Behavioral Health Specialist to develop post-discharge care plans addressing needs and barriers, ensuring smooth recovery and effective hand-off to longitudinal care.
- Perform regular check-ins guided by the TOC program, including post-discharge home visits and weekly follow-ups for four weeks, ensuring provider visits are completed and addressing member needs promptly.
- Meet members in various community settings such as homes, SNFs, IRFs, shelters, and hospitals, providing support for both clinical and non-clinical needs.
- Conduct comprehensive medication reconciliation and address contracted and company-prioritized quality gaps, ensuring proper chart documentation and appropriate ICD or CPT coding as evidence of gap closure.
- Utilize care facilitation, electronic health records, and scheduling platforms to collect data, document member interactions, organize information, track tasks, and communicate effectively with the team, members, and community resources.
- Track TOC-related metrics for assigned members, logging new TOC events and follow-up metrics to monitor progress effectively.
- 3+ Years of experience
- Graduate of an accredited school of nursing (R.N.)
