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Transitions Care Manager - RN 

About the Organization CommuniCare Family of Companies is a privately held, multi-faceted healthcare management company in operation since 1984 that specializes in nursing homes, assisted living facilities and rehabilitation units. Our company's historic passion for excellence is evident in every facet of our service continuum. We are leaders in the long-term care industry and we take immense pride in our opportunity to deliver the highest quality of care. We're excited about your interest in joining CommuniCare and your desire to uphold our mission of Serving with Pride.  
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Transitions Care Manager - RN Required

The Communicare Family of Healthcare Companies is recruiting an experience health care professional to fill an exciting new position in the Greater Cleveland/Akron area!

The mission of the Transitions Care Manager is to provide person-centered coordination of care to short-stay residents. This position will ensure that the patient's and family's goals are met and the best possible outcomes achieved, which will allow the resident to return to the highest level of independence possible. The position must work independently and within the care team to provide support, education, coaching, care management, and care coordination for the resident as it relates to the transition of care from the hospital to the center, transitions of level of care within the center, and the transition back into a community-based setting.

Responsibilities will include:

  • Perform initial assessment within 24 hours of admission
  • Ascertain primary care physician and specialists and provide them with follow up notification
  • Provide general center orientation and expectations of level of care of a skilled nursing facility
  • Coordinate a short term plan of care to flow into the MDS assessment
  • Create a road map to include goals, estimated length of stay, and initial discharge plan after coordination with clinical assessment of immediate needs and comorbidities
  • Attend Utilization Review Meetings, Update road map accordingly, Communicate updates to patient and family
  • Together with center leadership, Develop home-going education plan for family and patient
  • Meet with resident and family as needed to update and provide opportunitites for additional coaching and realignment of goals
  • Communicate with clinical team on changes in patient care road map
  • Assists patient and family for successful medical services visits by educating them on questions to ask regarding medications, conditions, etc.
  • Collaborates with social worker to obtain financial, HCB and social services
  • Upon admission, Establishes discharge plan as goal on road map.
  • Prior to patient's transition home:
    • Schedules appointment with primary care physician and necessary specialists
    • Reconciles medication with PCP and notify PCP of outstanding labs
    • Facilitates family meeting
    • Ensures home health services are in place
    • Participates with therapy on home safety evaluation one week prior
    • Completes Transition Check List to ensure that all the above were accomplished

As a CommuniCare employee, you will enjoy an excellent salary and a comprehensive benefits package in a fun, team environment!

Position Requirements
  • Must be a Registered Nurse
  • Must have 3 - 5 years nursing experience
  • Case Management experience a plus
  • Must have an understanding of post-acute care
  • Must have an understanding of chronic disease management, specific to geriatrics
  • Must have experience working on an IDT team
  • Must have established HCBS relationships
Full-Time/Part-Time Full-Time  
Location Cleveland Region  
Shift -not applicable-  
Experience Level 3 - 5 years Nursing experience, case management a plus. Experience working on IDT team.  
Education Level Associate's Degree. RN license required.  

This position is currently not accepting applications.

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