Transition of Care CM - Registered Nurse

At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues - caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.CVS Aetna takes a team-based approach to providing outstanding patient care. Transitional Care Manager is an integral part of the team. The TCM is the primary member of the CVS Health clinical care team and facilitator of interdisciplinary collaboration and care continuity across care settings and systems, empowering the patient and/or caregiver to play an active and informed role in post-ED/Observation and post-hospitalization care plan execution.

The TCM role is to support members and staff in transition from care settings, discharge planning processes, including identifying and addressing barriers, and building relationships with providers and care teams across various sites of care (e.g. ED, hospital, SNF, primary care clinics). This role prioritizes the relationship with the member/family and inpatient facility; providing high-quality, member-centered care; preventing avoidable readmissions; and managing efficient resource utilization.

• Manage members through transitions of care, either face to face in the facility or telephonically, within a defined geographical area and care setting.
• Advocate for the member throughout the care continuum to ensure access to resources and resolution to all barriers to care.
• Identify opportunities for improved program workflows, increased internal and external partnerships, and higher quality member care.
• Maintain real-time and accurate records of member status through care transitions within CVS Health's internal inpatient platform.
• Adhere to CMS, state specific and NCQA compliance criteria as related to Transitions of Care.

• Evaluate patient status post-ED visit or observation stay through a clinical assessment and medical record review.
• Triage to determine appropriate follow-up care and next steps, including reviewing medication lists and scheduling follow-up appointments with the appropriate provider and/or specialists.
• Engage directly with inpatient physicians, case managers, medical directors, and hospitalists (where applicable) to facilitate safe and timely discharge, appropriate follow-up care, and next steps.
• Coordinate with the Utilization Management team to review medical and payer records to ensure appropriate length of stay and identify any barriers to discharge.
• Assist Utilization Management team with access to external medical record information (if available) when needed to make appropriate determinations.
• Establish relationships and ensure patient/family are informed of member condition, plan of care and discharge plan, all discharge instructions, medication reconciliation; rationale of Utilization Management determinations and any financial information associated with such, potential for LTC transition (if applicable) and importance of timely PCP follow-up following discharge.
• Conduct structured clinical assessment to identify post-discharge needs, including but not limited to: medications, specialist appointments, home health, DME, caregiver support, social determinants of health, etc.
• Follow program procedures for documenting and tracking transitions interventions.
• Address identified post-discharge needs directly or via collaboration with other team members Collaboration and Communication with Internal Stakeholders
• Communicate and coordinate with internal stakeholders to identify and address patient needs (e.g. care team, social work, behavioral health, utilization management, Hard-to-Reach, Central Telehealth, etc.).
• Participate in regular meetings with CVS Health regional leaders, Program Director, Project Manager and other Transitional Care Managers on programmatic development and clinical learning to coordinate program implementation and ongoing management. Collaboration and Communication with the plan and appropriate lines of business.
• Identify partnership development opportunities and systems improvements. Coordinate with Regional Leaders and hospital partners to implement system improvements. Documentation, Tracking, Reporting and Training
• Participate in initial and ongoing required training to ensure appropriate implementation of transitions activities and programming.
• Participate with the TCM Coordinator and CM leadership in quality assurance activities.

• Active RN license in good standing within the state of practice
• Minimum of 2 years' experience in transitional care settings
• Exceptional communication skills and customer service orientation
• Innovative and independent problem-solving skills
• Ability to monitor and evaluate opportunities for cost-effective care options with high-quality outcomes
• Flexible, positive attitude
• Valid driver's license and ability to travel daily (anticipated 4-5 days/week onsite at various hospitals/facilities in OKC and/or Tulsa area)
• Reliable transportation
• Working knowledge of Microsoft Office Product Suite
• Traits such as:
  • Radiating positive energy
  • Assuming good intentions
  • Creating an unmatched patient experience
  • Driving clinical excellence
  • Taking ownership and delivering results
  • Being relentlessly determined

• Experience in utilization management
• Knowledge of Medicare/Medicaid and NCQA regulatory transitions of care criteria
• Bilingual (English/Spanish)

• Minimum Associates degree in Nursing
• BSN preferred

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.