Director, Transitional Care Program (RN)

The University of Texas MD Anderson Cancer Center in Houston is one of the world's most respected centers focused on cancer patient care, research, education and prevention. It was named the nation's No. 1 hospital for cancer care in U.S. News & World Report's 2022-2023 rankings. It is one of the nation's original three comprehensive cancer centers designated by the National Cancer Institute.

Care Coordination

· Identify and mitigate factors contributing to readmissions at a systemic level, working proactively to collaborate with interdisciplinary teams to develop and implement novel solutions and support Transitional Care Management team in implementing best practices for post-discharge patient management.

· Work with interdisciplinary teams to identify key post-discharge care and options for care to address any urgent/emergent issues post-discharge for our patients. Identify areas where new solutioning is needed and participate as a key strategic partner in solution design and launch.

· Work with interdisciplinary teams to design and optimize appropriate materials needed for post-discharge care and facilitate team access to these resources.

· Work collaboratively with Case Management Navigators, AskMDAnderson, Patient Navigators and clinical teams in the inpatient and outpatient setting to successfully assess and address patient needs at the systemic level.

· Builds workflow alignment and clarify between Transitional Care Managers and clinical disease management teams.

· Partner with key external stakeholders (home health, hospice, etc.) to ensure patient needs are met post-discharge at a systemic level.

Knowledge Management & Team Partnership

· Demonstrate understanding of patient needs and clinical/operational best practices.

· Maintain and apply clinical and institutional knowledge to render best possible post-discharge support to patients/caregivers.

· Recognizes unique needs of cancer population, and similarities/differences to other chronic medical conditions.

· Supports team with clinical expertise when needed.

· Establishes care management best practices and trains team on them.

· Holds team accountable for performance metrics.

· Supports team by addressing and helping to resolve challenges as they arise.

· Demonstrate competency in job related tools such as MS Office (Outlook, PowerPoint, Word), OneConnect (Epic), Zoom/Teams, and telephone system.

· Proactively obtain and integrate relevant training, ongoing education, professional development, and certifications for the role and ensure Transitional Care Management team does the same.

· Contribute to creative problem-solving, evaluate progress and identify and/or report obstacles/barriers.

· Serve as a dyad leader (in concert with the Director, Value Initiative) in solving problems related to patient Transitional Care Management to facilitate continuous improvement in post-acute patient management at a systemic level.

· Utilize available data to identify trends related to high-risk readmissions, develop interventions and continuous improvement strategies. Work collaboratively to move interventions/strategies from inception to implementation to activation.

Human Resources Management

· Perform quality control review of communications, materials, and customer feedback to continuously refine quality of service provided by Care Management team.

· Provide empathetic, emotionally intelligent support to team through active listening, just culture problem solving, and timely responses.

• • Directs all facets of human resource management within the Transitional Care Management team in consultation with the Director, Value Initiatives and CVQO including recruitment, selection, and credentialing and performance of classified staff.
  • As needs are identified, requests incremental positions using approved processes with well developed, thoughtful, data driven justifications.
  • Coaches and counsels employees, and when required, implements the disciplinary process within institutional guidelines.
  • Consults with CQVO and Director, Value Initiatives to execute all personnel actions including hiring, merit increases, terminations, promotions and reclassifications.
  • Conducts educational activities for department personnel
  • Other duties as assigned.

Bachelor's degree in Nursing. Eight years of professional nursing experience in an oncology hospital or clinic setting, to include three years of experience in case management practice and three years of management experience. Successful completion of the LEADing Self Accelerate program may substitute for one year of required supervisory or management experience. Current State of Texas Professional Nursing license (RN) and an Accredited Case Manager certification (ACM) from the American Case Management Association or Certified Case Manager certification (CCM) from the Commission for Case Managers within 180 days of entry into job. Basic Life Support (BLS) or Cardiopulmonary Resuscitation (CPR) certification. It is the policy of The University of Texas MD Anderson Cancer Center to provide equal employment opportunity without regard to race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, disability, protected veteran status, genetic information, or any other basis protected by institutional policy or by federal, state or local laws unless such distinction is required by law. http://www.mdanderson.org/about-us/legal-and-policy/legal-statements/eeo-affirmative-action.html