The RN Transitional Care Manager will play a crucial role in managing the care of patients once they are discharged from a hospitalization and move on to receive post-acute services at a skilled nursing facility or home health.

ESSENTIAL JOB DUTIES AND RESPONSIBILITIES

• Oversee and coordinate all aspects of patient care post-hospitalization, ensuring a seamless transition from hospital to post-acute care settings in collaboration with Belong and partner teams
• Monitor patient progress within the post-acute setting of care (Skilled Nursing Facility, Inpatient Rehabilitation, Home Health) to ensure that patients continue to progress toward returning to their baseline functioning and have the necessary support
• Work closely with interdisciplinary **care** teams to develop and implement individualized care plans.
• Assess patient care needs and determine the appropriate level of care, services, and resources.
• Monitor and track patient outcomes, readmission rates, and other key metrics to identify areas for improvement in care transitions.
• Review medical records and treatment plans to ensure care is provided efficiently and within clinical guidelines.
• Monitor patient progress and adjust care plans as necessary.
• Conduct weekly or biweekly virtual calls with post-acute care providers to review patient cases and ensure care is necessary and advancing the goals of the patient.
• Collaborate with primary care providers, specialists, and other healthcare professionals to ensure that patients receive comprehensive, high-quality care.
• Maintain comprehensive, up-to-date records of patient care, progress, and outcomes to ensure patients’ experience and transition of care is smooth

SUPERVISORY RESPONSIBILITIES

This role does not have supervisory responsibilities.

REQUIRED PROFESSIONAL EXPERIENCE AND QUALIFICATIONS

• 3+ years of clinical experience ideally with some hospital discharge case manager experience
• 1+ years of experience in managed care utilization management
• Excellent communication, organization, and case management skills.
• Strong understanding of healthcare regulations and standards.
• Ability to work independently and as part of a team.
• Compassionate, patient-centered approach to care.
• Ability to collaborate with partner institutions and individuals
• Self-directed and independent mindset to problem-solve challenges and escalate issues appropriately

 PREFERRED PROFESSIONAL EXPERIENCE AND QUALIFICATIONS

• Experience working in a fully distributed environment.

EDUCATION AND TRAINING

• Nursing degree is required.
• Bachelor of Science in Nursing is preferred.
• Master of Science in Nursing is a plus.

 LICENSE AND CERTIFICATION

• Registered Nurse (RN) with active, unrestricted nursing license.
• Case Management Certification is a plus.

TRAVEL

• This role may require some travel based on business needs.

SALARY RANGE

• $80,000-$100,000