RN Care Manager Adult Care/Transitions

Philadelphia, PA, US, 19104

Job Type: 

Req ID: 22779

Shift: Days

Employment Status: AF - Active - Regular - Full Time 

Job Summary

The RN Care Manager will focus on adult aged patients at CHOP who will transition care to adult medicine. The RN Care Manager will work closely with the Transition to Adult Care Team. The Registered Nurse (RN) Care Management Coordinator or “Care Manager” provides care management services to a panel of medically complex patients or populations of patients who have risk factors that are amenable to care management interventions.  The RN Care Manager facilitates the continuity of a patient’s care by functioning as a liaison between primary care providers (PCPs), outpatient specialty care providers and inpatient care teams, as well as payers, medical equipment suppliers, home care providers, subacute and chronic care facilities and community resources.  S/he collaborates with ambulatory, emergency department and inpatient care teams with the goals of optimizing communication among care providers, promoting seamless transitions between care settings and facilitating the appropriate use of health care resources. 

Job Responsibilities


1. Practice

a. General care coordination responsibilities:

i. Identify patients in need of care coordination and maintain a patient database.

ii. Provide care coordination services to an assigned panel or population of patients and their families.

iii. Develop and maintain patient-centered, intra-disciplinary, longitudinal plans of care and monitor patients’ progress toward care plan goals.

iv. Advocate for patients and families and promote communication and collaboration to keep all care team care members informed of patients’care needs and to ensure that patients access and benefit maximally from available health care resources.

v. Facilitate transitions across care settings.

vi. Assist patient and family with access to health care services as needed.

vii. Teach, coach and counsel patients and their families to build independence and skills for self-management.

viii. Monitor and evaluate patients’ outcomes and communicate outcomes to health care teams.

ix. Use information systems to document and track care coordination interventions

x. Transfer patients to higher or lower levels of care management support as appropriate.

b. Outpatient care coordination responsibilities:

i. Communicate regularly with PCPs and relevant specialists regarding acute and chronic patient care issues and intra-disciplinary care plans.

ii. Review medical records prior to encounters and participate in outpatient visits as necessary to assist in the development and updating of care plans.

iii. Participate in care team meetings to discuss active clinical issues and progress toward goals.

iv. Establish routine communication plans and communicate regularly with patients and families to assess ongoing care needs and to facilitate proactive care planning, including regular telephone contact.

v. Serve as a liaison with insurers/payers, review resource utilization and eligibility and identify the need for and facilitate obtaining additional health insurance services.

vi. Complete letters of medical necessity, referrals and prior authorizations as needed. vii. Collaborate with home nursing companies and Durable Medical Equipment (DME) providers. viii. Identify and develop relationships with community resources to support patient’s needs and makes referrals when appropriate.

Job Responsibilities (Continued)

c. Inpatient care coordination responsibilities:

i. Respond to referrals from inpatient teams, primary care providers or referring hospitals/facilities prior to discharge, and provide consultation on enrollment in longitudinal care management services.

ii. Establish relationships with patients who are newly enrolled in care management services prior to discharge and collaborate with the inpatient teams regarding discharge plans and anticipated outpatient care needs.

iii. Serve as a longitudinal resource for inpatient teams to obtain relevant information and updates about patients during initial and subsequent admissions, and collaborate with inpatient teams regarding outpatient care needs and discharge plans.

iv. Facilitate scheduling post-discharge follow up telephone encounters and visits with the PCPs and specialists.

v. Coordinate plans for follow up visits with care providers and for laboratory and diagnostic studies after discharge.

vi. Attend inpatient family meetings and care conferences when necessary to integrate inpatient care with patients’ longitudinal, intra-disciplinary care plans.

d. Emergency Department care coordination responsibilities;

i. Serve as a resource to Emergency Department providers for information about patients that will inform the Emergency Department plan of care.

e. General registered nursing duties (including but not limited to);

i. Obtain and document patients’ histories.

ii. Perform and document physical assessments.

iii. Conduct telephone triage and refer patients to appropriate services.

iv. Perform and/or interpret basic laboratory tests.

2. Professionalism and Leadership

a. Assist with surveys and other data collection activities to measure the effectiveness of care management interventions.

b. Support strategies and changes as needed to improve the care management program. c. Serve as an institutional expert on care coordination and transition management.

3. Research

a. Read, analyze and synthesize nursing and other scholarly articles and research studies; share knowledge with colleagues.

b. With assistance, apply research findings to clinical practice.

c. Seek opportunities to participate in research studies.

Job Responsibilities (Continued)


4. Research

a. Read, analyze and synthesize nursing and other scholarly articles and research studies; share knowledge with colleagues.

b. With assistance, apply research findings to clinical practice. c. Seek opportunities to participate in research studies.


5. Learning

a. Identify learning needs of self and others and assists in the development of a learning plan.

b. Apply education and training from departmental in-services and external sources to unit practices to enhance Nursing practice.

c. Participate in the development/presentation of education programs.

d. Demonstrate health care informatics competency in order to manage patient care, outcome data and current and emerging health care technology.


6. Resource Management

a. Participate in promoting quality, efficient and cost effective care.

b. Monitor own usage of supplies and equipment/identify opportunities for improvement and makes recommendations.

c. Manage own time to accomplish direct/indirect care in a cost efficient manner.


Required Licenses, Certifications, Registrations

BLS - Basic Life Support

RN / Temp Practice Permit

CCTM by the AAACN OR acquire certification in 3 years of being placed in position

Required Education and Experience

Required Education: Graduation from ACEN and/or CCNE accredited school of nursing or college. BSN required. 


Required Experience: At least five (5) years of nursing experience required.

Preferred Education, Experience & Cert/Lic

Preferred Experience: Pediatric experience preferred. Nursing experience with a combination of outpatient and inpatient experience preferred.

Additional Technical Requirements

Computer Competency

  • Navigation and basic search functions of the Internet using Internet Explorer
  • Use of Outlook 2007 email, opening of attachments, attaching new files to emails and saving attached files to computer
  • Basic use  of computers, printers, monitors, patient care devices,  and Fax machines

Information Literacy

  • Use of Internet and Intranet to look up basic electronic resources for practice
    • Ability to find and print Patient Family Education Documents

Information Management Literacy

  • Navigation of electronic health information records and ability to review specific patient data in a clinical information system
  • Understanding of policies and procedures around timeliness of care, use of a clinical information system and support of safe nursing practice
  • Ability to discuss data presented in charts and tables
  • Discuss the responsibilities of each user of an electronic record related to confidentiality and privacy
  • Coordination of patient care information in a fragmented environment where there is partially online and partially paper references

All CHOP employees who work in a patient building or who provide patient care are required to receive an annual influenza vaccine unless they are granted a medical or religious exemption.

Children's Hospital of Philadelphia is committed to providing a safe and healthy environment for its patients, family members, visitors and employees. In an effort to achieve this goal, employment at Children's Hospital of Philadelphia, other than for positions with regularly scheduled hours in New Jersey, is contingent upon an attestation that the job applicant does not use tobacco products or nicotine in any form and a negative nicotine screen (the latter occurs after a job offer).

Children's Hospital of Philadelphia is an equal opportunity employer. We do not discriminate on the basis of race, color, gender, gender identity, sexual orientation, age, religion, national or ethnic origin, disability or protected veteran status.

VEVRAA Federal Contractor/Seeking priority referrals for protected veterans.  Please contact our hiring official with any referrals or questions.

CHOP Careers Contact 

Talent Acquisition

2716 South Street, 6th Floor

Philadelphia, PA 19146 

Phone: 866-820-9288




Nearest Major Market: Philadelphia

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