Transitions Of Care (Toc) Rn Care Manager

The RN Transition of Care RN Manager is a critical member of the care team consisting of nurses, dietitians, pharmacists, social workers, community health workers, and physicians. This position will be collaborating closely with complex renal patients in their home, facility, by phone and electronically as needed. The primary focus will be to improve the movement of a patient from one care setting to another (hospital, skilled care, rehab, or long term care)

 

Somatus offers a Hybrid Telehealth environment with a combination of remote days and visits to members.

• Conduct Transition of Care assessments that include the medical, behavioral, pharmaceutical, and social needs of the patient, identify gaps in care and barriers to good health; the RN TOC Manager is expected to conduct approximately 12 - 15 assessments per week and manage a panel of about (70) seventy assessed patients.
• Based on this assessment, and in conjunction with the patient, patient’s nephrologist & PCP, and other members of the care team, create and implement a care plan that will address identified needs, remove barriers to care, and improve the health of the patient.
• Coordinate care by serving as the advocate and resource for the patient, their family, and their provider(s).
• Facilitate care across the continuum of Care, spanning settings such as the home, hospital, skilled nursing facility, and acute care facility.
• Manage patients during periods of Transitions of Care to facilitate effective transitions and minimize avoidable readmissions.
• Assess the patient’s knowledge of their discharge care requirements and renal condition and provide education and self-management support.
• Provide ongoing reassessment and follow-up to improve patient outcomes.
• Provide clinical oversight to non-licensed support team of community health workers and health coaches and licensed support team of social workers and renal dieticians, and delegate tasks as appropriate.
• Other duties as assigned

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.

• Bachelor’s degree in nursing preferred.
• 3-5 years of nursing experience in case management or care management, preferably coordinating care across multiple settings
• Current, unrestricted compact Registered Nurse license
• Valid BLS certification ONLY from a licensed AHA or American Red Cross training facility or provider.
• Ability to travel throughout the assigned region and comfortable with conducting home and facility visits (up to 75% same day travel) depending on assigned market.

Knowledge, Skills, and Abilities:

• Demonstrates empathy, enthusiasm, a deep sense of humor, and a strong work ethic.
• Experience collaborating with vulnerable patient population (ESRD, geriatrics, minorities, low income, uninsured, etc.)
• Ability to establish rapport with patient and family by inquiring and listening.
• Familiar with electronic medical records
• Competence using MS Office products and telecom devices.
• Core values consistent with a patient-centered approach to care
• Proactively acts as a patient advocate and responds with resolve.
• Knowledge and experience to empower patients in self-management and shared decision making.
• Effective written and verbal communication skills demonstrating respect and cultural awareness during interactions with clients.
• Strong analytical and critical thinking skills.

Physical Requirements

• The employee is frequently required to use hands to finger, handle, or feel; and reach forward with hands and arms. Depending on assigned market the employee may frequently lift and/or move up to (25) twenty pounds and occasionally lift or move (50) fifty pounds.

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.
Our priority is the health and safety of our members, colleagues, partners, and community. Proof of COVID-19 Vaccination is required for employment. If you are unable to be vaccinated for medical reasons or sincerely-held religious beliefs, we will consider requests for reasonable accommodations consistent with our policy, and where we are able to provide such accommodations without undue hardship to the company pursuant to applicable law. All requests for proof of vaccination or for exemptions from the vaccination requirement will be subject to any limitations stipulated by current state and/or federal laws.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Somatus, Inc. provides equal employment opportunity to all individuals regardless of their race, color, creed, religion, gender, age, sexual orientation, national origin, disability, veteran status, or any other characteristic protected by state, federal, or local law. Further, the company takes affirmative action to ensure that applicants are employed, and employees are treated during employment without regard to any of these characteristics. Discrimination of any type will not be tolerated.