JOB SUMMARY

The Transitions Care Manager position is a hybrid position focused on transitional care management, linkage to care, and navigation as well as on site care management within a primary care setting. This care manager provides outreach and navigation for individuals transitioning from acute care facility back to the community and primary care, including work with existing patients of the primary care practice, and those identified by staff of acute care facilities as lacking a primary care home and needing connection to primary care (e.g., the UNC/PHS Carolina Health Net Program). The Care Manager will assess needs, barriers and provide care coordination to meet individual patient needs. The care manager will provide support and expertise to the clinic team via assessment, planning, and implementation of the care plan. The Care Manager promotes patient-centered and team-based care through effective communication with patients, the care management team, medical team, acute care facility, and center staff. The Care Manager promotes continuity of care through support in navigating the health system, initiating and following up on referrals, providing outreach to patients through population health efforts, providing patient education and addressing high need concerns of medically complex patients. The Care Manager is responsible for resource identification, periodic reports, accessing acute care facility reports and addressing any gaps or needs identified. Independent critical thinking skills and decision making is necessary in this position. 

MINIMUM QUALIFICATIONS

• • Bachelor's degree required, in a healthcare related field is preferred. (nursing, public health or social work)
  • One to two years nursing, case management, or social work experience preferred. 
  • Bilingual Required

PATIENT POPULATION SERVED

Pediatric, Adolescent, Adult, Geriatric, Prenatal.  Diverse population including but not limited to chronically ill and limited English speaking

patients. 

PHYSICAL DEMANDS/ WORKING CONDITIONS

Extended periods of walking, standing, and extended periods of sitting.  Performance of essential duties requires close and distance vision, hearing

acuity, dexterity and stamina. Clinical environment with exposure to chemicals, pathogens and patient body fluids. Ability to work under stressful

conditions. Ability to multitask.  Adaptability to change assignments unexpectedly. Must have a personal vehicle for transportation between sites

and to other community networks within our service area.  Participation in training sessions outside of PHS.  Requires moderate computer skills

and use of other office equipment.