Belong Health is hiring a
RN Transitional Care Manager

Summary

Join Belong Health as a RN Transitional Care Manager and 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.

Requirements

• 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

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

Preferred Qualifications

Experience working in a fully distributed environment