Registered Nurse – Case Manager – Transitions Of Care

Overview

• Provide telephonic clinical outreach to patients post-discharge to ensure safe transitions of care.
• Focus on reducing readmissions and improving patient outcomes through education and care coordination.
• Collaborate with interdisciplinary teams to support continuity of care and address care gaps.
• Utilize evidence-based models to align with value-based care objectives and improve quality performance.
• Conduct comprehensive assessments to identify risks and barriers to recovery.
• Document interventions and outcomes in electronic health records for compliance and reporting.
• Support professional nursing standards and participate in ongoing education initiatives.

Key Responsibilities & Duties

• Perform post-discharge telephonic outreach following established workflows and timelines.
• Conduct medication reconciliation and reinforce discharge instructions for patients.
• Coordinate follow-up appointments and facilitate referrals to community resources.
• Monitor hospital admission feeds to identify care transition opportunities.
• Collaborate with care teams to address clinical concerns and social barriers.
• Support closure of quality gaps and adherence to value-based care protocols.
• Participate in quality improvement initiatives to enhance care transition effectiveness.
• Maintain accurate documentation in EHRs to support audits and performance monitoring.

Job Requirements

• Active Registered Nurse (RN) license in good standing; multi-state licensure preferred.
• Bachelor of Science in Nursing (BSN) required.
• Minimum of 2 years clinical nursing experience; care management or transitions of care preferred.
• Experience in telephonic or remote patient support strongly preferred.
• Familiarity with post-acute care settings and discharge planning.
• Proficiency with EHRs and care management systems.
• Strong clinical assessment, critical thinking, and communication skills.
• Ability to manage multiple patients and priorities in a remote environment.