Registered Nurse -Transitional Case Manager - Strategic Insurance Development - Per-diem

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Position Summary

The Transitional Care Manager is a professional nurse who applies theory based professional knowledge in the planning, facilitation and provision of quality patient and family education for adults with a diagnosis of a chronic disease. The Transitional Care Manager uses a mentorship framework incorporating the concepts of consultation, support and empowerment to assist the clinical nurse, and other healthcare professionals in the delivery of care. Their clinical expertise enables them to provide advanced, evidenced based care to patients and positively impact the assessment, planning, and evaluation of patients diagnosed with a chronic disease. The Transitional Care Manager utilizes and applies change theory in matters related to clinical practice; fosters communication when interacting with staff, patients and other members of the healthcare organization. The Transitional Care Manager assists with navigating from and between the acute care setting and the outpatient arena.

Education, License, & Cert

Bachelor’s Degree in Nursing or related field required. With an employment agreement, will consider applicant who is actively pursuing their bachelor’s degree. Master’s Degree preferred. Certified in Case Management, within one year of hire. Licensed Nurse Practitioner considered.


A minimum of Five years’ experience in an acute healthcare setting, preferably with case management, utilization review, and payor knowledge. Experience caring for patients diagnosed with a chronic disease. Demonstrated capability and competence in clinical nursing practice, teaching, and leadership.

Essential Functions

A. Clinical Practice

1. Leads/provides bedside education and care based on identified patient, staff, family needs.

2. Participates in establishing and evaluating standards of care in area of expertise and in evaluating nursing care against these standards. Utilizes conceptual frameworks and theory as a basis for clinical practice. Collaborates / consults with other health professionals in planning nursing practice.

3. Maintains clinical skills and expertise related to advanced chronic disease management; clinical practice and staff development, while acting as a role model/ mentor to nursing staff.

4. Advances professional nursing through research, publication, organizations, and other activities.

5. Initiates and facilitates teach back sessions

6. Conducts a discharge needs assessment and addresses areas of concern.

7. Facilitates provider follow-up; meets with providers regarding patient population

8. Provides post discharge patient interaction via phone call or home visit within 48 hours of discharge, as well as ongoing weekly phone calls for 30 days post-discharge

9. Collaborates with non-Guthrie providers and facilities to coordinate the care of patients discharged from a Guthrie facility.

10. Reviews and assesses for appropriate consults

11. Identifies high risk patients prior to discharge

12. Collaborates with Care Coordination staff, and non-Guthrie PCP offices to provide warm hand-offs and ensure continuity of care.

B. Case Management

1. Serves as patient advocate in representing the patient’s best interest to the providers and payers.

2. Procures insurance authorizations where indicated to ensure appropriate cost-effective care. Acts as an institutional advocate by managing care in a cost-effective manner and communicating with third party payers.

3. Utilizes and applies industry standard and accepted utilization review tools to validate/support level and location of medical care needed.

4. Supports development, integration and monitoring of clinical pathways and guidelines.

5. Maintains accountability for coordination of care processes for the patient during the acute care phase, and during the transition phase to outpatient services.

6. Initiates and participates in interdisciplinary patient care conferences and rounds as appropriate.

7. Completes assessment form, i.e., PRI and other referral procedures as needed for continuing care needs.

8. Provides leadership for clinical staff regarding complex patient care concerns and/or care of patients who do not achieve expected outcomes.

9. Identifies individual patient discharge needs in collaboration with other clinical team members beginning upon initial admission assessment and continued reassessment throughout an episode of care. Takes the initiative in working with the interdisciplinary health care team and patient/family to identify a treatment regime which streamlines care, reduces or controls costs and enhances patient outcomes.

10. Maintains compliance with documentation requirements and guidelines of third-party payers, regulatory and government agencies.

11. Participates in long-range planning to meet the needs of high-risk patients and/or population

12. Participates in performance improvement and educational activities

13. Incorporates available current evidence-based data for clinical care management

C. Administration

1. Participates in performance improvement activities and research as needed.

2. Encourages development of leadership skills and strong team relationships in members of the nursing staff.

3. Provides clinical expertise for decision making while utilizing principles of change theory to effect smooth processes of change. Also, based on clinical expertise, he/she identifies technological advances in nursing and makes appropriate recommendations.

4. Remains informed of current practice advancements and research findings and provides for dissemination of research developments.

5. Helps bring evidence-based practice to the bedside for patients diagnosed with an identified chronic disease.

Other Duties

1. The Transitional Care Manager must be able to demonstrate the knowledge and skills necessary to provide care appropriate.

2. The individual must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patients status and interpret the appropriate information needed to identify each patients requirements as to his/her specific needs, and to provide the care needed as described in the appropriate policies and procedures.

3. It is understood that this description is not intended to be all inclusive, and that other duties may be assigned as necessary in the performance of this position.

Joining the Guthrie team allows you to become a part of a tradition of excellence in health care. In all areas and at all levels of Guthrie, you’ll find staff members who have committed themselves to serving the community.

The Guthrie Clinic is an Equal Opportunity Employer that welcomes and encourages diversity in the workplace.

The Guthrie Clinic is a non-profit, integrated, practicing physician-led organization in the Twin Tiers of New York and Pennsylvania. Our multi-specialty group practice of more than 500 physicians and 302 advanced practice providers offers 47 specialties through a regional office network providing primary and specialty care in 22 communities. Guthrie Medical Education Programs include General Surgery, Internal Medicine, Emergency Medicine, Family Medicine, Anesthesiology and Orthopedic Surgery Residency, as well as Cardiovascular, Gastroenterology and Pulmonary Critical Care Fellowship programs. Guthrie is also a clinical campus for the Geisinger Commonwealth School of Medicine.

  • 1
  • Negotiable
  • None
  • None
  • Re-7829
  • Permanent
  • 4

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