Care Transitions Nurse: Case Management & Discharge

IntelliResume; Spokane (WA); On-site; USD 68,000 - 113,000; Full time

Job summary

Kaiser Permanente in Spokane, WA is seeking a Transitions of Care Liaison Nurse to coordinate discharge planning and follow-up care for recently discharged patients. This full-time, on-site role emphasizes case management and patient advocacy.

You’ll contact patients after discharge for medication review, support home transitions, and work with a care team to reduce readmissions. Requires ADN and WA RN license; prior case management is preferred.

Qualifications

• ADN required.
• Prior case management experience preferred.
• Current RN license in Washington.

Responsibilities

• Call members recently discharged for medication review and assessment.
• Follow up with members for up to 30 days for check-ins as needed.
• Assist members in transitioning to home settings to reduce readmissions.
• Ensure patients referred to case management meet criteria.
• Assess patients' physical, mental, financial, and psychosocial status.
• Develop patient-centered case management plans based on assessments.
• Coordinate and implement interventions using evidence-based guidelines.
• Collaborate with healthcare professionals regarding the plan of care.
• Monitor and evaluate patient responses to therapeutic interventions.
• Facilitate referrals for home health care, long-term care, and hospice services.

Skills

Patient advocacy

Case management

Communication

Care coordination

Education

ADN

Job description

Kaiser Permanente in Spokane, WA is seeking a Transitions of Care Liaison Nurse to coordinate discharge planning and follow-up care for recently discharged patients. This full-time, on-site role emphasizes case management and patient advocacy.

You’ll contact patients after discharge for medication review, support home transitions, and work with a care team to reduce readmissions. Requires ADN and WA RN license; prior case management is preferred.