Care Manager Transition of Care

Position Purpose: Performs care management duties to assess, plan and coordinate aspects of medical and supporting services across the continuum of care for post-discharge members, promoting quality and cost effective care. Completes medication review for pre-admission and post-discharge reconciliation. Works with the care management and coordination teams to identify transition support services. Key Details : Must reside in the state of Texas Evaluates the needs of the member by completing post discharge assessments for members transitioning from healthcare facilities Evaluates medication and performs reconciliation between pre-admit and post-discharge medications Develops a care/service plan and collaborates with discharge planners, providers, specialists, and interdisciplinary teams to support member transition and discharge needs Assesses member current health status, resource needs, services, and treatment plans and provides appropriate interventions Facilitates the transition into active care management based on member needs Provides or facilitates education and resource materials to members, authorized caregivers, and providers to promote wellness activities to improve member overall quality of care Facilitates services between Primary Care Physician (PCP), specialists, medical providers, and non-medical resources as necessary to meet the medical and socio economic needs of members May perform telephonic, digital, home and/or other site outreach to assess member needs