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Anderson Regional Med Center - Full Time Care Transition Manager - Meridian, MS - RehabCare in Meridian, Mississippi For Sale

Type: Medical, For Sale - Private.

Summary: The CTM will facilitate consented patients transitions across the Kindred continuum of care. Emphasis will be placed on active patient/caregiver participation and collaboration with healthcare providers, using a holistic approach, to improve care transitions, decrease complications and exacerbations that often occur during transitions, prevent and/or decrease re-hospitalizations, and improve the patients experience and internal/external customer satisfaction. The CTM will accomplish this by facilitating evidence-based essential interventions that include: medication management; transition planning; patient/caregiver engagement and education; up information transfer; follow-up care; patient/caregiver advocacy; and healthcare provider engagement and accountability. Minimum qualifications: Education: Bachelor's degree in a healthcare field Masters degree preferred License/Certification: Valid license in the state employed Certification in one of the following is desirable: ACM (Accredited Care Manager) CCM (Certified Case Manager) Experience: 5 years of current healthcare case management experience in a multi-level post acute provider, or a managed care plan Essential Functions: The Care Transitions Manager will facilitate: 1. Patient/Caregiver Engagement and Education Across the Continuum v Education, engagement and counseling of the patient/caregiver that will enable active participation in their own care, and informed decision-making related to their plan of care v Patient/caregiver centered transition communication 2. Transition Plan of Care Support and Collaboration v Safe transition of the patient from one level of care to another, including home, or from one practitioner to another v Identification and communication with the healthcare provider(s) to facilitate and coordinate the patient's transition plan v Indentification and Management of patient/caregiver transition needs v Use of evidence based transition planning tools v Completion of transition summary v Timely, effective sharing of important healthcare and psychosocial information among the patient/caregiver and the healthcare providers 3. Supports Communication with the Patient's Healthcare Provider v Responsibility and accountability for the transition of the patient/caregiver until discharged from the program through identification of and collaboration with the patient's PCP v Case Management Involvement v Education and counseling of patient/caregiver and open and timely communication among healthcare providers, PCP and patient/caregiver. 4. Medication Management v Safe use of medications by patient, based on the patient's plan of care with each transition v Assessment and review of the patient's medication intake with each transition v Patient/caregiver education of R/T medications v Plan for medication management when transitioned to the next level of care 5. Support of the Follow-up Plan of Care v Follow up care that promotes the safe transition of the patient from one level of care/provider to another v Telephone and/or face to face reinforcement of the transitional plan of care with the patient/caregiver and the healthcare provider v Enhance the transition of care process through clear, accurate and timely communication of the patient's plan of care to both the sending and receiving healthcare provider, until transition is complete. The CTM will: Serve as a patient/caregiver advocate to facilitate positive outcomes for the patient, which are achieved through collaboration with the patient/caregiver as well as healthcare providers participating in the patient's plan of care Encourage the appropriate use of health care services and improve quality of care and maintain costs Empower the patient/caregiver to: problem solve to the achieve desired goals; be their own advocate; and to be an active participant in the determination of their own plan of care Attend Interdisciplinary Team Meetings, review the patient's medical record, and gather clinical information from the current care delivery team, and the patient/care giver, in order to assess progress toward goals, discharge and anticipated length of stay. Encourage patient/caregiver engagement and involvement in care by providing education regarding the patient's medical condition, disease and symptom management, and referral sources and community resource options. Conduct a thorough review of the patient's care plan and progress to identify if a patient is potentially in need of a specialist referral, education, patient-specific goals that have not been addressed, or a return to a higher level of care Provide information to patient/caregiver about Kindred post-acute discharge options, and adhere to Kindred's Patient Choice Policy and Procedure at all times. Collaborate with members of the inter-disciplinary team by gathering the necessary information required to develop a safe and effective transitional plan to the next level of care Communicate clinical and personal transitional goals throughout the post acute care continuum to promote optimal recovery. Communicate to the receiving provider as the patient transitions from one level of care to the next (includes bidirectional admissions and discharges) Enhance the transition of care process through clear and timely communication of the patient's plan of care to both the sending and receiving healthcare providers until the transition is complete. Provide telephonic and/or onsite support to patients who are transitioned to the next level of care, and conduct patient survey within 72 hours post transition. All pertinent information collected will be reviewed and assessed with appropriate healthcare team providers. Document patient encounters, including completion of structured encounters and patients/caregiver's involvement in each encounter until discharged from the program Enter specific data elements into electronic dashboard with each patients transition or discharge Knowledge, Skills and Abilities: Ability to work independently and collaboratively with other healthcare team members. Ability and willingness to self-motivate, prioritize and implement change in order to improve effectiveness and efficiency; ability to adapt to changing patient or organizational priorities Ability to manage conflict, stress and multiple simultaneous work demands in an effective and professional manner Ability to make independent decisions in accordance with established policies and procedures; decision making and problem solving will require a combination of analysis, evaluation and interpretive thinking. Knowledge and appreciation of cultural diversity in the provision of care. Demonstrates advanced clinical assessment skills to meet job requirements. Superior interpersonal, verbal, and written communication skills and ability to communicate effectively with patients and their family members, as well as physicians and colleagues at all levels of the organization. Knowledge of reimbursement methods and regulations (Managed Care, Medicare, and Medicaid) that promotes the provision of cost-effective healthcare and the preservation of patient's benefits while obtaining optimal recovery and managing a clinically appropriate length of stay. Computer literacy, including proficiency in MS applications, but not limited to data entry and/or report generation. Detail oriented, with a focus on accuracy, while effectively managing multi-site duties Ability to travel to and from a variety of care settings.
Source: http://www.jobs2careers.com/click.php?id=xxxxxxxx46.96

State: Mississippi  City: Meridian  Category: Medical
Medical in Mississippi for sale

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