Partners Health Management · 1 day ago
Transitions Health Management Coordinator, Licensed (NC)
Gastonia, NC
Full-time
Onsite
Entry, Mid Level
1+ years expPartners Health Management is focused on providing comprehensive care to its members. The Transitions Health Management Coordinator ensures continuity of care for members transitioning between various healthcare settings, working closely with care teams to improve quality of life and prevent hospital readmissions.
WellnessHealthcareFitnessHealth CareMedical
Hiring Manager
Annelies Kisiah
Responsibilities
Support members transitioning from inpatient settings to the appropriate lower or lateral level of care
Provide subject matter expertise, within scope, regarding member’s physical and/or behavioral health to support the development and delivery of a whole person approach to Care Management
Collaboratively works with other Partners team members, behavioral health providers, primary care physicians, specialty care providers and other community partners and stakeholders to support members in their home communities
Conducts on site visit with member during their stay in residential or inpatient settings (e.g., acute, ED and long–term stay facilities)
Conduct outreach to the member’s providers
Obtain a copy of the discharge plan and review the discharge plan with the member, facility staff and Tailored Care Manager
Facilitate clinical handoffs
Assist the member in obtaining needed medications prior to discharge, ensure an appropriate care team member conducts medication reconciliation/management and support medication adherence
Develop a ninety (90) day post-discharge transition plan prior to discharge from residential or inpatient settings, in consultation with the member, facility staff and the member’s care team, that outlines how the member will maintain, or access needed services and supports, transition to the new care setting, and integrate into the community
Communicate and provide education to the member and the member’s caregivers and providers to promote understanding of the ninety (90) day post-discharge transition plan.(Assist with scheduling of transportation, in-home services, and follow-up outpatient visits with appropriate providers within a maximum of seven (7) Calendar Days post-discharge, unless required within a shorter timeframe
Ensures follow-up with the member within forty-eight (48) hours of discharge
Appropriately escalate high risk/high visibility and/or complex barriers/needs members who may have difficulty transitioning out of the facility in a timely manner to supervisors. High risk can involve Health and Safety of a member, staff, or organizational risk
Review cases with clinical complexity with direct supervisor and follow escalation protocols to ensure timely engagement from members or our Medical Team and Provider Networks
Obtain information releases that will improve care management activities on behalf of the member
Qualification
Required
Master's degree in a human service field and one (1) year of full-time experience with the population served
Licensure as a registered nurse (RN) and one (1) year of full-time experience with the population served
Current unrestricted LCSW, LCMHC, LPA, LMFT, LCAS, or RN licensure with the appropriate professional board of licensure in the state of North Carolina
Must reside in North Carolina
Must have ability to travel as needed to perform the job duties
When visiting hospitals, staff may be asked to verify the status of vaccination or immunization or a statement of exemption (including but not limited to COVID) to meet the requirements of the hospital
Preferred
Licensed to practice as a Registered Nurse in North Carolina and two years of experience in nursing; care management/care coordination; care transition experience
Experience in collaborative care
Benefits
Annual incentive bonus plan
Medical, dental, and vision insurance with low deductible/low cost health plan
Generous vacation and sick time accrual
12 paid holidays
State Retirement (pension plan)
401(k) Plan with employer match
Company paid life and disability insurance
Wellness Programs
Public Service Loan Forgiveness Qualifying Employer
Company
Partners Health Management
You will often hear people call Partners a North Carolina local management entity/managed care organization or LME/MCO.
501-1000 employees
Funding
Current Stage
Late StageLeadership Team
Bob Moore
Senior Advisor to the CEO
Rhett Melton
Chief Executive Officer (CEO)
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