Transition Support Case Manager

Transition Support Case Management (TSP CM) is a collaborative process performing the primary role functions of assessment, planning, facilitation, and advocacy for options and services to meet a patient's health needs post discharge. Responsibilities include assisting the client and/or family caregivers with follow through of discharge plan and homecare instructions to prevent rehospitalization. In this role, the TSP CM empowers patients and their families towards greater autonomy and improved health and safety outcomes post discharge. The TSP CM will serve all high-risk medical clients including, but not limited to, vent dependent clients and clients with disorders of consciousness. This process requires an organized individual with excellent communication skills.

Job Responsibilities:

• The TSP Case Manager is an integral part of a patient's recovery process, helping to continue coordinating the efforts began by the interdisciplinary rehabilitation team. Job Functions:
• Attends interdisciplinary team meetings and identifies patients who qualify for the Transition Support Program.
• Collects thorough and accurate chart review prior to discharge home via EMR review
• Collaborates with interdisciplinary team and obtains report from referring CM and primary RN.
• Meets with the client/family prior to discharge to explain the role and function of Transition Support services.
• Work closely with client’s physicians to address needs/concerns (medical needs, therapy goals, vocational interests/goals, and patient financial status, etc.) as they arise.    
• TSP CM calls every client/family at a minimum of once a week and is available throughout the week to answer unlimited calls and emails from client/family.  
• Develops a mutually acceptable plan of care to maximize health and safety goals.
• Helps facilitate community re-entry and assists clients/caregivers in locating community-based resources.
• Assists with the identification of financial grants/waivers and assists with the completion of applications.
• Continues the coordination of physician orders to outside suppliers. 
• Manages requests for medication assistance and completes other required forms and letters.  
• Identifies patient and family education needs and provides necessary re-education.
• Provides ongoing education, guidance, and support post discharge, with a strong focus on medical, financial, and psychosocial needs.
• Assist clients and caregivers in determining personal goals that lead towards improved long-term health and a meaningful life post injury.     
• Completes thorough and accurate documentation in electronic records.
• Practices proper safety techniques in accordance with Center and departmental policies and procedures. Responsible for the reporting of employee/patient/visitor injuries or accidents, or other safety issues to the supervisor and in the occurrence notification system.
• Monitors and ensures compliance with all regulatory requirements, organizational standards, and policies and procedures related to area of responsibility. Identifies potential risk areas within area of responsibility and supports problem resolution process.

Required Minimum Education:

• Bachelor’s degree in Nursing

Required Minimum Certifications:

• CCM required within 2 years.

Required Licensure:

• Active Georgia RN license or NLC/eNLC Multistate License.

Required Minimum Experience:

• A minimum of at least 5 years of experience as an RN required. Experience working with patients who have sustained brain and/or spinal cord injuries is preferred.

Required Minimum Skills:

• Excellent judgment, time management and communication skills required. 
• Applicant should be self-motivated, dependable, and able to meet deadlines. 
• Must demonstrate critical thinking, cultural diversity, and advocacy.
• Ability to appropriately handle sensitive and confidential information.

Physical Demands:

• Sedentary work involves sitting most of the time but may involve walking or standing or exerting up to 15 pounds of force occasionally or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body.
   

Working Conditions:

• Some potential for exposure to blood and bodily fluids.

The above statements are intended to describe the general nature and level of work performed by people assigned to this classification.  They are not intended to be an exhaustive list of all job duties performed by the personnel so classified.