Transition Discharge Coordinator Job at Western Health (Sunshine)

RN Care Manager

Inpatient Care Managers are Registered Nurses who independently assure patients ...

Location

United States , Salem

Salary:

52.52 - 80.11 USD / Year

Kaiser Permanente

Expiration Date

Until further notice

Requirements

Minimum of two years combine RN experience in the following areas: Med/Surg (hospital acute care)
ICU (hospital acute care)
Emergency Department
Home Health
Skilled Nursing Facilities
Hospice
Long Term Acute Care
Inpatient Rehab
Utilization Management
Successful completion of an RN program by date of hire

Job Responsibility

Independently assure patients are admitted to the correct level of care for accurate billing and reimbursement
Provide quality, cost effective clinical coordination/care management in acute care and emergency care settings
Manage patients with routine and complex transition planning needs by: independently assessing needs, developing and implementing plans of care for transitions across care settings
Serve as expert consultants and educators for physicians and other health care team members for discharge and transitional care, coordination of internal and community resources
Support the evaluation and improvement of systems of care to support the optimal utilization of health care resources, while maintaining quality of patient care
Assume primary accountability for anticipating, assessing, developing, implementing, documenting, advising, and communicating a safe transition plan of care for patients with complex care needs
Coordinates post-discharge patient care needs to assure the timely and effective discharge of routine and complex patients from the hospital setting
Independently and proactively completes and documents patient assessments which are thorough, timely, age appropriate, and reflect psychosocial support systems, care needs, health plan benefits, level of care determinations for hospitalized patients
Coordinates and communicates with patients, families, and the health care team to develop mutually agreeable plans of care that optimize the use of resources to support the particular needs of individual patients
Facilitates resolution of issues which present barriers to safe transfers through the use of patient/team care conferences to assure the efficient transition to a lower level of care and to assure the patient/family receives the right care at the right time so that quality and utilization of resources are simultaneously enhanced

What we offer

Medical, Vision & Dental
Retirement Plans
Tuition Reimbursement
Supportive Teams & Resources
Career Growth & Development

Parttime

Registered Nurse Navigator Population Health

The RN Navigator in Population Health is responsible for coordinating and managi...

Location

United States , Irving

Salary:

Not provided

CHRISTUS Health

Expiration Date

Until further notice

Requirements

Bachelor’s Degree in Nursing preferred
3 years of clinical experience required
2 years of case management experience required
Experience working in a primary care value-based care organization is required
Knowledge of population health management principles is required
RN license in the state of employment or compact is required
One of the following certifications is required within 2 years of hire: Certified Case Manager (CCM) by CCMC or Nursing Case Management Certification (CMGT-BC) by ANCC
Must have strong clinical assessment skills
Must have excellent communication and interpersonal skills
Must be able to work independently and as part of a team

Job Responsibility

Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders
Care Coordination of Complex/Chronic conditions: Manages and coordinates care for patients with chronic conditions, complex medical needs, and assists with Discharge Planning: Helps plan and coordinate the discharge process for members leaving hospitals or long-term care facilities, ensuring a smooth transition to home or another care setting
Care Coordination - Transitions of Care: Outreach to patients that qualify for Transitions of Care (IP Discharge) and ensure they understand their medications, educate patients on managing their conditions and knowing when to seek help, stressing the importance of scheduling and attending follow up appointments, and teaching them to recognize the signs that their condition might be worsening
Patient Assessment: Conduct comprehensive assessments to identify patient needs, barriers to care, and social determinants of health
Care Planning: Develop and implement individualized care plans based on patient assessments, clinical guidelines, and patient preferences. Focuses on reducing preventable admissions, readmissions, and preventable ED visits by supporting discharge planning to the next level of care and educating patients about the appropriate setting for care
Advocacy: Serve as an advocate for patients or clients, helping them to navigate the healthcare system, understand their treatment options, and access the services they require
Collaboration: Work closely with healthcare providers, social workers, and community resources to ensure a holistic approach to patient care
Monitoring and Evaluation: Track and communicate to PCPs and specialty care providers any significant changes to members' concerns, along with any updates on members’ status
Documentation: Maintain accurate and timely documentation of patient interactions, care plans, and outcomes in the electronic health record (EHR) system
Quality Improvement: Participate in quality improvement initiatives to enhance patient care and population health outcomes

Fulltime

Registered Nurse Case Manager (Maternal/Child)

Full time 2nd shift RN, Case Manager - This would be a position for our Maternal...

Location

United States , Tucson

Salary:

Not provided

Tucson Medical Center

Expiration Date

Until further notice

Requirements

Bachelor's degree in nursing or associate degree in nursing
Two (2) years of nursing or case management experience
For NICU – Three (3) years of NICU nursing experience
Current RN licensure permitting work in state of Arizona
Basic life support (BLS) required
Some departments may also require current CPR instructor certification, Neonatal Resuscitation Provider (NRP) certification
Knowledge of direct patient care and critical care procedures and techniques, tools, and responses required to ensure optimal patient care
Skill in evaluating cases and determining appropriate care and status
Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations
Ability to write reports, business correspondence and collaborate with case management leadership on the creation and update of necessary standards of work

Job Responsibility

Works with physicians and multidisciplinary team members to develop a plan of care for each assigned patient from admission through discharge
Ensures patient is progressing toward desired outcomes by continuously monitoring patient care through assessment and/or evaluation
Assesses and responds to patient/family/care giver needs by coordinating efforts of other treatment team members
Identifies and resolves barriers that hinder effective patient care
Improves quality and completeness of documentation
Collaborates and communicates with multidisciplinary teams in all phases of discharge planning process
Assesses, creates, implements evaluates, and modifies timely discharge plans
Assesses, intervenes, and acts as a resource in medical-legal situations for patients and families
Enters nursing orders for their assigned patient caseload related to discharge planning and transitional care needs
Assists patients and families in making difficult decisions, while honoring their preferences and values

Fulltime

Embedded Transitional Care Manager

The Embedded Transitional Care Manager - RN (TCM-RN) plays a critical role in en...

Location

United States , Indianapolis

Salary:

54095.00 - 116760.00 USD / Year

CVS Health

Expiration Date

Until further notice

Requirements

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

Job Responsibility

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

What we offer

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

Fulltime

Complex Inpatient Medical Social Worker

Provides care management/social work services to Complex patients, families, and...

Location

United States

Salary:

33.05 - 49.60 USD / Hour

Advocate Health Care

Expiration Date

Until further notice

Requirements

Master’s Degree in Social Work
LSW license issued by the State in which the team member practices (WI & IL Divisions)
Accredited Case Manger SW (ACM-SW) certification issued by the American Case Management Association (ACM) needs to be obtained within 2 years, or Certified Case Manager (CCM) issued by the Commission for Case Manager Certification (CCMC) needs to be obtained within 2 years, or Certified Social Worker in Health Care (C-SWHC) issued by National Association of Social Workers to be obtained within 2 years
3 years of hospital care management experience
Ability to prioritize and organize work
Effective communication skills
Utilization of critical thinking and timely decision making
Ability to navigate the electronic health record
Basic utilization of MS Office products
Knowledge of Medicare A and B guidelines

Job Responsibility

Provides care management/social work services to Complex patients, families, and individuals including perming thorough patient psychosocial assessments, screening, determination of needs evaluation, appropriate interventions and follow up, and discharge planning
Implements targeted interventions and patient-family centered care plans to achieve optimal health outcomes
Collaborates and negotiates effectively with socially complex patients, family and the clinical team while striving to achieve patient and organizational goals regarding care needs, choices, and satisfaction during discharge planning and care transitions
Provide continuity of care and discharge planning services for socially complex patients compliant with regulatory standards
Provides advanced care management guidance and mentorship to frontline care management team members fostering a culture of excellence and continuous improvement
Initiates internal and external referrals to ensure timely progression of care and transitions for socially complex patients
Documents discharge planning interventions and utilization review activity according to department and organization standards in a timely manner
Advocates for patients and their families to ensure their voices are heard and their needs are met within the healthcare system while optimizing the utilization of hospital resources ensuring cost-effective care delivery and adherence to regulatory guidelines
Communicates effectively with the healthcare team regarding socially complex patients
Serves as a leader of the multidisciplinary rounds and work closely with clinical team members, hospital departments and ancillary services to identify and resolve barriers to discharge, expedite care delivery to avoid delays in timely service provision, and implement and report on care coordination and discharge planning

What we offer

Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program

Fulltime

Licensed Practical Nurse

Nonotuck Resource Associates, Inc. is seeking a Licensed Practical Nurse (LPN) t...

Location

United States , Brockton

Salary:

78400.00 - 81400.00 USD / Year

Nonotuck

Expiration Date

Until further notice

Requirements

Current MA Licensed Practical Nurse (LPN) License
Computer and organizational planning
Two-year recent experience with elders, those who have been diagnosed with ID/D, ABI, or who have chronic conditions affecting their ability to live safely in the community
Strong interpersonal and communication skills
Ability to work collaboratively in a team environment
Background Check Required
Valid driver's license with an excellent RMV record (subject to RMV background check)

Job Responsibility

Intake and Assessments
Complete thorough intake assessments for new referrals and subsequent assessments as required
Conduct nursing assessments and submit Prior Approval requirements as per members' insurance coverage
Supervision and Training
Provide supervision, training, and evaluation of caregivers to ensure high-quality care delivery
Foster a collaborative and supportive environment within the caregiving team
Individualized Plans of Care
Develop and maintain detailed Individualized Plans of Care tailored to each member's unique needs
Ensure plans are regularly reviewed and updated to reflect changes in health or circumstances
On-Site Visits

What we offer

Sign-On Bonus $3,000
401(k) with Employer Match
Health, Dental, & Vision Insurance
Disability and Life Insurance
Flexible Spending Account, Health Savings Account, and Dependent Care Account Options
Paid Time Off
13 Paid Holidays
Annual increase with Profit Sharing
Hybrid Office/Work from Home Model
Mileage reimbursement

Fulltime

Registered Nurse - Case Manager

We’re building a world of health around every individual — shaping a more connec...

Location

United States , Philadelphia

Salary:

66575.00 - 142576.00 USD / Year

CVS Health

Expiration Date

April 30, 2026

Requirements

Current RN license in assigned state is required
Bachelor degree in nursing preferred
Minimum of 6-8 years nursing experience
Certified Case Manager (CCM) required, or willingness to obtain within 12 months of hire, unless candidate has 2-3 years of relevant care/case management experience
2+ years experience in transitional nursing, emergency room nursing, care coordination, discharge planning, or home health is strongly preferred
Demonstrated skill in motivational interviewing, patient activation, time management, and navigating community and social resources
A flexible and positive attitude
Comfort with ambiguity and change
High emotional intelligence as evidenced by ability to evaluate/perceive a situation from multiple lenses and understand various perspectives in coming to problem resolution
Access to reliable transportation and ability to travel throughout the communities OSH serves

Job Responsibility

Manages an assigned caseload of complex patients in a value-based care environment, with a focus on driving reduced admissions, readmissions, and medical utilization
Accountable for panel metric performance in admission prevention, readmission prevention, and transitions of care metrics
Owns overall care coordination for assigned patients, functioning as the primary point of contact and ensuring alignment, accountability, and follow-through across the care team
Manage transitions of care episodes for patients on their panel, including timely completion of structured clinical assessments to identify post-discharge needs, medication reconciliation on behalf of the PCP, and addressal of identified needs directly or via collaboration with other team members
Collaborates patient’s PCP, family/caregiver, Social Worker, Behavioral Health Specialists, and other care team members, as needed to evaluate the individual's needs, goals, and plan of action and ensure care plan progression
Ensure timely documentation of key clinical assessments after admissions, while balancing in-center care team planning meetings
Lead in-person interdisciplinary care planning meetings to ensure effective care coordination and management between providers visits
Perform timely nursing assessments and provide patient education for chronic condition management and transitions of care
Educate patients and families, empowering them in their care, and advocating for their needs
Document visits in electronic health record according to internal standards

What we offer

Mission-focused career impacting change and measurably improving health outcomes for Medicare patients
Paid vacation, sick time, and investment/retirement 401K match options
Health insurance, vision, and dental benefits
Opportunities for leadership development and continuing education stipends
New centers and flexible work environments
Opportunities for high levels of responsibility and rapid advancement
Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility

Fulltime

Registered Nurse Case Manager

In partnership with the primary care provider, (PCP), the RN, Case Manager is th...

Location

United States , Philadelphia

Salary:

66575.00 - 142576.00 USD / Year

CVS Health

Expiration Date

April 30, 2026

Requirements

Current RN license in assigned state is required
Bachelor degree in nursing preferred
Minimum of 6-8 years nursing experience
Certified Case Manager (CCM) required, or willingness to obtain within 12 months of hire, unless candidate has 2-3 years of relevant care/case management experience
2+ years experience in transitional nursing, emergency room nursing, care coordination, discharge planning, or home health is strongly preferred
Demonstrated skill in motivational interviewing, patient activation, time management, and navigating community and social resources
A flexible and positive attitude
Comfort with ambiguity and change
High emotional intelligence as evidenced by ability to evaluate/perceive a situation from multiple lenses and understand various perspectives in coming to problem resolution
Access to reliable transportation and ability to travel throughout the communities OSH serves

Job Responsibility

Manages an assigned caseload of complex patients in a value-based care environment, with a focus on driving reduced admissions, readmissions, and medical utilization
Accountable for panel metric performance in admission prevention, readmission prevention, and transitions of care metrics
Owns overall care coordination for assigned patients, functioning as the primary point of contact and ensuring alignment, accountability, and follow-through across the care team
Manage transitions of care episodes for patients on their panel, including timely completion of structured clinical assessments to identify post-discharge needs, medication reconciliation on behalf of the PCP, and addressal of identified needs directly or via collaboration with other team members
Collaborates patient’s PCP, family/caregiver, Social Worker, Behavioral Health Specialists, and other care team members, as needed to evaluate the individual's needs, goals, and plan of action and ensure care plan progression
Ensure timely documentation of key clinical assessments after admissions, while balancing in-center care team planning meetings
Lead in-person interdisciplinary care planning meetings to ensure effective care coordination and management between providers visits
Perform timely nursing assessments and provide patient education for chronic condition management and transitions of care
Educate patients and families, empowering them in their care, and advocating for their needs
Document visits in electronic health record according to internal standards

What we offer

Paid vacation, sick time, and investment/retirement 401K match options
Health insurance, vision, and dental benefits
Opportunities for leadership development and continuing education stipends
New centers and flexible work environments
Opportunities for high levels of responsibility and rapid advancement
Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility

Fulltime

Transition Discharge Coordinator

Western Health

Location:
Australia , Sunshine

Category:
Nursing

Contract Type:
Not provided

Salary:

Job Description:

Job Responsibility:

Requirements:

Additional Information:

Job Posted:
March 18, 2026

Expiration:
March 22, 2026

Looking for more opportunities? Search for other job offers that match your skills and interests.

Similar Jobs for Transition Discharge Coordinator

RN Care Manager

Registered Nurse Navigator Population Health

Registered Nurse Case Manager (Maternal/Child)

Embedded Transitional Care Manager

Complex Inpatient Medical Social Worker

Licensed Practical Nurse

Registered Nurse - Case Manager

Registered Nurse Case Manager

Transition Discharge Coordinator

Western Health

Location:Australia , Sunshine

Category:Nursing

Contract Type:Not provided

Salary:

Job Description:

Job Responsibility:

Requirements:

Additional Information:

Job Posted:March 18, 2026

Expiration:March 22, 2026

Looking for more opportunities? Search for other job offers that match your skills and interests.

Similar Jobs for Transition Discharge Coordinator

RN Care Manager

Registered Nurse Navigator Population Health

Registered Nurse Case Manager (Maternal/Child)

Embedded Transitional Care Manager

Complex Inpatient Medical Social Worker

Licensed Practical Nurse

Registered Nurse - Case Manager

Registered Nurse Case Manager

Location:
Australia , Sunshine

Category:
Nursing

Contract Type:
Not provided

Job Posted:
March 18, 2026

Expiration:
March 22, 2026