Transitions of Care RN Case Manager
Core
Provide telephonic, short-term interdisciplinary care management for high-risk patients within 30 days post-discharge to prevent readmission and ensure safe navigation of the healthcare system.
Role type
RN Case Manager (Transitions of Care)
Builds
Coordinated post-discharge care plans and patient education programs for Medicare Advantage members.
Domain
Healthcare / Medicare Advantage / Transitions of Care
Required skills
RN licensure, telephonic case management, care plan development, patient education, comorbidity assessment, medication adherence support, interdisciplinary collaboration
Preferred skills
Medicare Advantage experience, Special Needs Plan experience, Population Health experience, clinical analytical thinking
Technologies
Data tools, telephony platforms
Responsibilities
Conduct patient assessments to identify comorbid conditions and psychosocial factors; develop and evaluate care plans in partnership with patients and caregivers; educate patients on chronic conditions and red flags; partner with Nurse Practitioners and Physicians for smooth handoffs; coordinate post-treatment care and DME needs; collaborate with Community Guides to identify community resources.
Seniority
Mid-level, hands-on IC