Transitional Care Management RN Case Manager
Melville, NY
United Staffing Solutions
5x8 hrs, Days
Referral Bonus

Position: Transitional Care Management RN - ambulatory
Schedule: Monday-Friday, 8:00 AM-4:00 PM, 40 hours a week; occasional weekends
Experience: 3 years ambulatory preferred; EPIC experience preferred
Required: NY RN license in hand and a bachelor's degree
Unit: Primary Care, West Babylon - quality and case management, supporting a new program the Quality Department is standing up
Duties: Coordinate and manage care transitions after discharge from inpatient, emergency, skilled nursing and other settings - outreach within 48 business hours, post-discharge assessment covering medication reconciliation, discharge instructions, barriers to care, symptoms and social determinants; schedule timely PCP and specialist follow-up; complete TCM documentation in EPIC; monitor high-risk patients for complications and readmission risk and escalate via SBAR. Collaborate with physicians, advanced practice providers, nurses, social workers, care managers and the hospital liaison, make referrals to home care, behavioral health, palliative care, pharmacy and community resources, and coach patients and caregivers on diagnoses, medications, treatment plans and self-management
Facility: Catholic Health Corporate, Melville NY