Embedded Transitional Care Manager

• Manage patients through transitions of care, either face to face in the facility or telephonically
• advocate for the patient throughout the care continuum
• identify opportunities for workflow improvements and partnerships
• maintain real-time records of patient transitions
• engage with physicians, case managers, and hospitalists
• coordinate follow-up care, medication reconciliation, and discharge planning
• collaborate with internal stakeholders and regional leaders on transitions initiatives
• participate in training, documentation, tracking, and quality assurance

• An active RN license within the state of practice in good standing
• willingness to obtain cross-state licensure, as needed
• Certified Case Manager (CCM) or equivalent case management certification required, or willingness to obtain within 12 months of hire
• 2+ years’ experience in transitional nursing, discharge planning, nursing case management, or home health
• experience in utilization management preferred
• knowledge of Medicare/Medicaid and NCQA regulatory transitions of care criteria
• exceptional communication skills and customer service orientation
• innovative and independent problem-solving skills
• ability to monitor and evaluate opportunities for cost-effective care options with high-quality outcomes
• Spanish-speaking preferred but not required
• a flexible, positive attitude
• valid driver’s license and ability to travel daily
• working knowledge of Microsoft Office Product Suite
• US work authorization

Spanish language skills preferred but not required

• Mission-focused career
• paid vacation and sick time
• investment/retirement 401K match options
• health insurance, vision, and dental benefits
• affordable medical plan options
• no-cost programs for health and wellness
• tuition assistance
• flexible schedules
• family leave
• dependent care resources
• colleague assistance programs
• retiree medical access