Care Transitions Program Manager

Sea Mar Community Health Centers, a Federally Qualified Health Center (FQHC) founded in 1978, is a community-based organization committed to providing quality, comprehensive health, human, housing, educational and cultural services to diverse communities, specializing in service to Latinos in Washington State. Sea Mar proudly serves all persons without regard to race, ethnicity, immigration status, gender, or sexual orientation, and regardless of ability to pay for services. Sea Mar's network of services includes more than 90 medical, dental, and behavioral health clinics and a wide variety of nutritional, social, and educational services. We are recruiting for the following position:

Sea Mar is a mandatory COVID-19 and flu vaccine organization

Care Transitions Program Manager – Posting #27372

Annual Salary: $75,000-95,000 DOE

Position Summary:

Sea mar Community Health Centers is seeking a full-time Care Transitions Program Manager (CTPM) for Seattle. The Care Transitions Program Manager provides oversight to programs and processes which support Sea Mar patients’ transitions across care settings, such as hospitals and skilled nursing facilities. This position supports the Medical and Quality Improvement department in serving as a liaison with external Health Facilities such as hospitals, Health Plans, community agencies, and other Sea Mar departments. The CTPM collaborates with staff in hospitals, and with Sea Mar providers in resolving gaps in care for frequent utilizers of hospital and other facility based services.

The CTPM assures continuity and coordination of care for patients before, during and after hospitalization, easing the transition for patients and families into and out of facilities. This position contributes to the success of financial, utilization, and quality goals by collecting and analyzing data related to patient utilization, closure in gaps of care, and effectiveness of interventions. The Manager is responsible for planning, developing, organizing, integrating, and managing the Care Transitions program, including management of staff and budget.

The Care Transitions Manager will also be assigned oversight responsibilities for Care Transitions staff. Staff to be supervised includes but is not limited to Care Transitions RNs. Management of staff includes hiring, reviewing performance of staff, disciplinary action, and separation.

This is a specialized position insofar as the CTPM will have a background working with patients in various settings (such as with hospice, home health, and acute care hospitals), and will have an understanding of patients with diverse medical, mental health, and social determinant of health challenges. Active participation in community-wide efforts/coalitions to provide comprehensive interdisciplinary care is expected.

Core Responsibilities

For Care Transitions Services

• Assists in the development of Care Transitions policies and procedures by researching and creating tools based on similar models of care.
• Serves as the “point person” for issues concerning Care Transitions within Sea Mar.
• Provides training and education to health care professionals and facility staff regarding Care Transitions as requested.
• Provides team supervision to all Sea Mar Care Transitions team members.
• Reviews Emergency Department Information Exchange (EDIE) reports as well as other data to identify patients requiring support with care transitions.
• Documents contact and services provided to patients.
• Collects, analyses, and reports data related to utilization of hospital and other care facilities, patient gaps in care, and success of interventions.

Productivity Standards

• Visits all sites every five to six weeks to evaluate program and support staff.
• Completes monthly reports and submits them timely.
• Completes assigned tasks within the required timeframe.

Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• The ability to work effectively with all persons and groups with respect and an awareness of cultural differences.
• Must have good organizational and communication skills.
• Demonstrate professionalism and appropriate boundaries in all interactions.
• The person in this position shall have no history or evidence of alcohol or other drug misuse for a period of three (3) years prior to the date of employment at the facility, and no misuse of alcohol or other drugs while employed at this facility.
• This individual cannot be a person who has been convicted of a felony within the last seven years or ever been convicted of assault, abuse, fraud, or crimes that have brought harm to another financially, emotionally, or physically.

Position Requirements:

• Ability to connect well and maintain effective relationships and professional rapport with staff, patients and other members of the care team; this individual must have strong communication skills.
• Ability to act professionally in client’s home setting, community setting, or clinic.
• Ability to navigate different systems in relation to managing patients care transition needs.
• Ability to understand medical terminology pertaining to chronic conditions, admitting diagnoses, medications, and discharge services.
• Ability to work with an interdisciplinary care team including Care Transitions staff, medical providers, nursing staff, care coordinators, behavioral health and support staff.
• Ability to perform independently and at the same time perform effectively and professionally as an interdisciplinary team member.
• Ability to understand systems to collect, analyze, and communicate information related to care transitions.
• Ability to travel throughout Western Washington approximately 25 percent of work time.
• Bilingual (Spanish/English) preferred.
• Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals.
• Ability to write routine reports and correspondence.
• Ability to speak effectively before clients or employees of the organization.
• Typing proficiency of at least 45 wpm.
• Demonstrable computer skills and an ability to learn computer applications from manuals and webinars with minimal supervision.
• Working knowledge of Microsoft Office.
• Ability to learn and proficiently use programs as may pertain to use of electronic health records.
• Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume.
• Ability to apply concepts of basic algebra and geometry.

Education and/or Experience:

• BSN/RN with two or more years working in discharge planning, care coordination, or care transitions. May consider other staff with Master’s Degrees in Healthcare or Social Work with extensive experience in hospital discharges or care transitions. Licenses and accreditations must be active and maintained while employed.
• Master's Degree or RN preferred.
• Experience working with staff with varied skill sets.
• Experience working with substance use disorders, chronic mental illness, and chronic health conditions.
• Experience working with community agencies.
• Strong knowledge of community resources.
• Experience with motivational interviewing, the teach back method, or patient counseling and education.
• Must complete agency and State mandatory trainings.
• English/Spanish bilingual strongly preferred.

Additional Requirements

• Must maintain up-to-date vaccination record.
• Will obtain CPR certification within initial probationary period and will maintain CPR certification throughout employment.
• Must have a valid driver’s license and proof of auto insurance.
• Must complete a pre-hire and annual TB test screening.
• Annual employee health screening required
• Annual TB test required
• Annual influenza vaccine required. Only exception is for employees with a medical or religious exemption approved by Administration. Employees with an approved medical or religious exemption must wear a mask at all times during the flu season.

What We Offer:

Sea Mar offers talented and motivated people the opportunity to work in a dynamic and growing community health organization. Working at Sea Mar Community Health Centers is more than just a job, it’s a fulfilling career with opportunity for advancement. The fringe benefits surpass most companies. For example, Full-time employees working 30 hours more, receive an excellent benefit package of Medical, Dental, Vision, Life Insurance, Prescription coverage, Long Term Disability, EAP (Employee Assistance Program), paid-time-off starting at 27 days per year + 10 paid Holidays. We also offer 401(k)/Retirement options and an exciting opportunity to work in a culturally diverse environment.

How to Apply:

To apply for this position, complete the online application and click SUBMIT or APPLY NOW. If you have any questions regarding the position, email Nicholas Ramirez, Senior VP at NicholasRamirez@seamarchc.org. Please reference the posting number on the subject of your email.

Sea Mar is an Equal Opportunity Employer

Posted 02/25/2025

Please visit our website to learn more about us at www.seamar.org. Follow us on Facebook, Twitter, and Instagram.

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