Care Transition Lead: Discharge & Coordination

Emerus; United States; On-site; USD 85,000 - 100,000; Full time

Job summary

Emerus in the United States seeks a Transitional Care Manager to oversee patient transitions from hospital to home using evidence-based care coordination. You will identify high-risk patients and work with hospital teams to optimize discharge planning and outcomes.

The role requires a nursing degree with RN license or LMSW, plus hospital discharge planning experience and proficiency with MS Office. Flexibility for after-hours work and telehealth assessments is valued.

Qualifications

• Bachelor Degree in Nursing with an RN license, or LMSW.
• One (1) year hospital clinical experience.
• One (1) year hospital discharge planning experience.
• Ability to work off-hours and on call.

Responsibilities

• Holistic patient assessment for discharge planning needs.
• Participate in hospital multidisciplinary daily rounds.
• Identify patient and family education needs to ensure participation in discharge planning.
• Identify patient concerns and gaps in care during discharge.
• Coordinate with Hospitalists and care teams to bridge gaps.

Skills

Holistic patient assessment

Discharge planning

Care coordination

Multidisciplinary teamwork

Communication skills

Telehealth assessments

Time management

Education

Bachelor Degree in Nursing (RN)

LMSW (multi-state)

Tools

Microsoft Office Suite

Job description

Emerus in the United States seeks a Transitional Care Manager to oversee patient transitions from hospital to home using evidence-based care coordination. You will identify high-risk patients and work with hospital teams to optimize discharge planning and outcomes.

The role requires a nursing degree with RN license or LMSW, plus hospital discharge planning experience and proficiency with MS Office. Flexibility for after-hours work and telehealth assessments is valued.