RN Transitional Case Manager
Carteret General Hospital - Morehead City, NC

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Responsible to the Outreach Services Coordinator at Carteret General Hospital. Consults with members of the Patient Care Services Leadership and Hospital Leadership staff as appropriate.
· The RN Transitional Care Manager collaborates with the client, social work case manager, and other health care providers to facilitate client access to those health and social services which enhance the client's health and well being and his/her ability to adhere to the prescribed medical treatment regimen in the most efficient and cost effective manner possible. The RN Transitional Care Manager provides services to the client in a variety of community and clinical settings. Works with the multidisciplinary team to identify patients at increased risk for readmission and provide care coordination services throughout the care continuum and into the outpatient setting by working with the Outreach Services team as well as other community partners and resources.
The Transitional Case Manager will:
1. Assess, plan, implement, coordinate, monitor and evaluate healthcare services to meet an individual’s specific health care needs in a cost effective manner.
2. Coordinate patient care with patient, family, staff, physicians, and ancillary/community services to promote quality and cost efficient care.
3. Use the nursing process to provide case management services to an assigned caseload. *Completes initial client/family assessments and problem lists. *Accurately identifies and prioritizes patient problems using critical thinking skills. *Collaborates with client, physicians, and other providers to develop a comprehensive plan of care. *Effectively communicates care plans and other client-related activities both verbally and in writing to appropriate personnel and agencies. *Utilizes clinical skills and assessments to work autonomously in outpatient, community settings and to communicate with physicians and other providers re: alterations in the plan of care. *Demonstrates the ability to use teaching, learning, and counseling skills.
· 4. Act as a client advocate for the development of community resources. *Maintains a directory of available services by geographical area and updates others about new services. *Consults others to identify potential community resources for resolving client health, psychosocial, or financial problems. *Functions as liaison to external agencies and relays information to others which may impact care and/or services of clients. *Demonstrates the knowledge and skills necessary to provide services appropriate to the age of the patient. *Develops and intitiates cost saving strategies to achieve decreases in patient resource utilization.
  • 5. Collaborates with regional hospitals *Identifies vulnerable high risk ED and inpatients. *Educates hospital team members and patients about available Network services. *Attends hospital multi discipline meetings. *Formulates effective post discharge care plan in conjunction with facility care managers. *Improves access to mental health resources upon discharge.

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