Registered Nurse – Case Manager – Transitions Of Care

Overview

• Provide telephonic clinical outreach to patients post-discharge to ensure safe transitions across care settings.
• Focus on reducing readmissions, closing care gaps, and improving patient outcomes through assessments and education.
• Collaborate with interdisciplinary teams to ensure continuity of care and support value-based care objectives.
• Utilize evidence-based models to enhance transitions of care effectiveness and quality performance.
• Document interventions and outcomes in electronic health records for reporting and monitoring purposes.
• Participate in quality improvement initiatives to optimize care delivery and patient satisfaction.
• Maintain professional nursing standards and active licensure to uphold accountable care practices.

Key Responsibilities & Duties

• Conduct post-discharge telephonic outreach to assess patient needs and barriers to recovery.
• Perform medication reconciliation and reinforce discharge instructions to ensure understanding.
• Coordinate follow-up appointments with healthcare providers and ancillary services.
• Monitor admission feeds to identify transitions of care opportunities and initiate outreach.
• Collaborate with care teams to address clinical concerns and social barriers.
• Facilitate referrals to community resources or internal programs to meet patient needs.
• Support quality gap closures related to medication adherence and follow-up care.
• Document all interventions and outcomes in compliance with organizational protocols.

Job Requirements

• Active Registered Nurse (RN) license required; Nurse Licensure Compact (NLC) preferred.
• Bachelor of Science in Nursing (BSN) required.
• Minimum of 2 years clinical nursing experience; 3 years preferred.
• Experience in care management, transitions of care, or case management preferred.
• Proficiency with EHRs, care management systems, and documentation tools.
• Strong clinical assessment, critical thinking, and patient education skills.
• Ability to manage multiple priorities in a remote environment effectively.
• Comfort working independently while collaborating with interdisciplinary teams.