Care Transition & Discharge Navigator

AbsoluteCARE Medical Center & Pharmacy; Baltimore (MD); On-site; USD 85,000 - 90,000; Full time

Job summary

AbsoluteCare Medical Center & Pharmacy in Maryland seeks a Transitional Care Manager to deliver in-person discharge planning, care coordination and integrated case management for hospitalized members. The TCM partners with inpatient facilities, health plans, and community providers to meet post-discharge needs and improve value-based outcomes.

Key duties include developing person-centered care plans, conducting post-discharge calls, coordinating follow-up with PCPs and specialists, arranging

Qualifications

• Must be willing and able to travel up to 80% of the time to local area facilities.
• Licensed RN by the state where practicing.
• Experience with discharge planning and care transition coordination in community settings.

Responsibilities

• Meet with members during inpatient admission and develop a PCCP.
• Call members post discharge to review instructions and schedule follow-up visits.
• Coordinate post-discharge plans including hospital follow-up and home health.
• Communicate with AbsoluteCare team and providers on discharge plans.
• Manage PCCP and member contact per regulatory requirements.
• Provide education with teach back on health conditions and treatment options.
• Attend clinical rounds and provide recommendations for level of care.
• Meet established KPIs and manage caseload per visit frequency.

Skills

RN License

Discharge planning

Care coordination

Travel up to 80%

MS Office

Communication skills

Driver's license

Bilingual (desirable)

Education

RN license (state)

CCM or CCTM credentials a plus

Tools

EMR documentation

Microsoft Office Suite

Job description

AbsoluteCare Medical Center & Pharmacy in Maryland seeks a Transitional Care Manager to deliver in-person discharge planning, care coordination and integrated case management for hospitalized members. The TCM partners with inpatient facilities, health plans, and community providers to meet post-discharge needs and improve value-based outcomes.

Key duties include developing person-centered care plans, conducting post-discharge calls, coordinating follow-up with PCPs and specialists, arranging