RN Clinical Care Manager – Rochester New York

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$30-$45 an hour

How will this role have an impact?

Transitions to Home (TTH) program improves quality and outcomes as well as patient engagement through the provision of both clinical care and social coordination services aimed at readmission prevention for recently hospitalized patients.

The Registered Nurse Care Coach (RNCC) is a member of the interdisciplinary team of patient-facing care coordinators working together with advanced practitioners (MD, NP, and PharmD), focusing on high-risk patients, medication safety, and PCP communication. This position functions in a telephonic model and will be a remote work from home position.

This role will report to our Clinical Manager of TTH.

What will you do?

• Conduct telephonic follow-up with patients and/or caregivers, identifying clinical and social needs and/or gaps in care
• Partner with social and clinical colleagues, PCP, and hospital-based clinical teams to help coordinate internal and external resources needed to manage the patient’s plan of care
• Perform triage assessments, escalating acute issues to Advance Care Provider team
• Assist with scheduling PCP/specialist follow-up
• Respond to patient and/or caregiver phone calls
• Provide education to patients and caregivers
• Participate in rounding with the TTH team
• Assist with improvement to workflow processes and commit to a focus on continuous process improvement

We are looking for someone with:

• RN license in good standing, required; compact state licensure status preferred
• Bilingual (English and Spanish speaking), required
• Strong working knowledge of medical conditions, interventions, treatment, and medications, required
• Expert telephonic nurse triage skills including ability to develop rapport, composure, active listening, critical thinking, problem solving, and assessment skills, required
• 2 years case management, utilization management or transitional care experience, preferred
• Motivational interviewing experience preferred
• Bachelor’s degree, preferred

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