TITLE:  Population Health Transitions Care Manager


The Transitional Care Manager (TCM) coordinates care for a select group of patients to guide them through the issues related to the transition from one level of care to another. This coordination of care is accomplished through a collaborative process working with patients, family members, the acute/post-acute interdisciplinary teams, and home care.
The TCM engages both patients and their families while providing objective information and support throughout the care continuum. This position optimizes patient care transitions thereby reducing unnecessary post-acute utilization and decreasing the likelihood of readmission.
Coordination of care during patient transitions is accomplished through a collaborative process working with the patient, family members and the acute, post-acute and primary care interdisciplinary teams. The interdisciplinary team usually consists of, but is not limited to the physicians/NPs, case managers, social workers, nursing, home care, and rehab staff.
The goal is to optimize patient care transitions by 1) assisting in setting appropriate patient/family expectations, 2) assuring an appropriate post-acute plan and utilization of services, 3) assisting the post-acute team in development of an appropriate discharge plan for post-acute discharge, and 4) assuring communication with primary care and community supports to decrease the likelihood of readmission.
The TCM follows ACO and/or other risk contract patients discharged to an associated skilled nursing facility (SNF) network. Using established clinical decision support tools and length of stay (LOS) criteria, the TCM works with the network of collaborative SNFs to ensure the execution of efficient patient care plans within the approved LOS timeframe. Through onsite and telephonic rounding, the TCM develops relationships with SNF administrative and clinical staff to promote optimal and efficient patient care. This position requires a broad knowledge of academic medical centers/community hospitals, post-acute levels of care, clinical systems/electronic medical records (EMRs), and rehabilitation expertise. This position requires a broad knowledge of clinical care, payer rules including Medicare, and health services across the continuum of care.
The TCM will demonstrate prudent professional and clinical judgment, effective problem-solving skills, critical thinking, excellent organizational and interpersonal skills, creativity, flexibility, and the ability to multi-task. The TCM will update and educate him/herself in matters relating to care coordination, applicable Federal and State regulations, risk management, community resources and other pertinent topics.

PRINCIPAL DUTIES AND RESPONSIBILITIES: Indicate key areas of responsibility, major job duties, special projects, and key objectives for this position. These items should be evaluated throughout the year and included in the written annual evaluation.

1. Evaluates ACO patients referred for admission to SNF for level of care; utilizes and applies level of care and SNF LOS decision support software at time of transition, during the SNF stay, and at time of SNF discharge.
2. Utilizes EMR (EPIC), case management referral systems, Admission Discharge Transfer notification systems, and other patient identification technology to identify, track patients, and document in the EMR.
3. Facilitates coordination of care for ACO patients in SNFs during the stay and at discharge; for high-risk (iCMP) patients, in collaboration with the iCMP RN Care Coordinators.
4. Establishes the anticipated LOS for ACO patients at time of transition and monitors and provides LOS guidance to the SNF facility.
5. Through onsite and telephonic rounding, ensures timely implementation of the plan of care at the SNF and appropriate patient progression to discharge, helping to navigate any barriers to care.
6. Visits patients and/or families to explain role, program, and ensure all elements critical to the plan and trajectory of care have been communicated, including the goal LOS.
7. Participates in patient and family meetings, as needed, to support the plan of care and discharge plan. Advocates for patient and family as needed.
8. Communicates with PCPs, Specialists, iCMP RN Care Coordinators and/or other health care clinicians to provide routine warm hand offs or to alert providers about potential issues during or upon discharge from program.
9. Documents weekly rounds with SNF, care plan meetings, and post-discharge assessments (PDAs) in EMR and routes messages to providers and clinicians as needed.
10. May perform PDAs, including medication reconciliation, within established timeframes and documents in EMR. Works to resolve any identified issues that could lead to an unnecessary re-admission.
11. Participates in SNF Mini-Collaborative Meetings, individual SNF meetings, and TCM program management meetings to contribute to discussions, reviewing data, and focus on improvement efforts per established priorities.
12. Along with program/hospital leadership, reviews TCM program clinical and financial outcomes and recommends then executes program adjustments as indicated.

Competencies Required/ Skills

 Strong assessment, critical thinking, and problem-solving skills.
 Strong interpersonal skills including excellent oral, written, and telephonic skills and abilities.
 Ability to work independently with minimal supervision.
 Ability to work in an interdisciplinary team-based environment.
 Goal oriented and accountable.
 Demonstrated organizational skills and an ability to manage routine work, triage and reset priorities as needed.
 Must be able to work in a fast-paced complex setting and demonstrate performance agility in a continuously changing environment.
 Strong oral and written communication skills.
 Demonstrates appropriate communication skills for the patient population served.
 Computer skills with the ability to quickly demonstrate competency in various software applications.
 Strong data analytic skills and interest in tying data to clinical outcomes.
 Flexibility with tasks and assignments as program needs dictate. Examples include assisting colleagues and providing coverage during vacations/unexpected illness/holiday time.


 Physical Therapist (PT), Physical Therapist Assistant (PTA), Occupational Therapist (OT), Registered Nurse (RN)
 Graduate of an accredited program related to licensure is required. Bachelor’s or master’s degree preferred
 Minimum 2+ years of experience of acute hospital or post-acute care setting required
 Minimum of 2+ years of case management, utilization review and discharge planning experience preferred
 Knowledge of Medicare regulations and guidelines at SNF preferred
 Evidence of continued education and professional development


 Flexibility to work in a variety of locations as well as remotely.
 On-site settings include acute hospital and post-acute skilled nursing facility setting.
 Flexibility required to meet with patients/family and providers in the acute hospital and/or post-acute facility required.
 Travel between locations is required.
 Hours and work schedule will be flexible to meet the needs of patients, families, and facility staff, but will generally follow a Monday-Friday eight-hour work schedule.

The above statement reflects the general duties considered necessary to describe the principal functions of the job and are not considered a detailed description of work requirements inherent in the position.

To apply for any position, please email:  nprideaux@pchi.partners.org