Case Management Nurse - 258400

Medix™; Tucson (AZ); Hybrid; USD 70,000 - 90,000; Full time

Job summary

Medix seeks a fully bilingual English/Spanish RN Case Manager to support high-risk patients through chronic care management, transitions of care, and coordinated care planning. This is a direct-hire, hybrid role based in Tucson, with 2–3 days onsite and remaining days remote.

Monday–Friday, 8:00 AM–5:00 PM, with on-site days yet to be finalized. Experience in case management, transitions of care, discharge planning, utilization management, or managed care is preferred, along with strong

Qualifications

• BSN required for licensure and clinical practice.
• Fully bilingual in English and Spanish is REQUIRED.
• Professional communication in both English and Spanish; basic Spanish alone is not sufficient.
• Minimum 2 years of RN experience.
• At least 2 years in one or more: Case Management, Transitions of Care, Chronic Care Management, Utilization/Managed Care.
• Knowledge of pre-acute and post-acute care settings and resources.
• Strong communication, organization, clinical assessment, and care coordination skills.

Responsibilities

• Oversee chronic care management and transitions of care for high-risk patients.
• Serve as clinical resource to multidisciplinary teams.
• Conduct comprehensive assessments addressing physical, mental, and social risk factors.
• Develop and coordinate individualized care plans based on patient needs.
• Perform telephone triage and address or escalate patient concerns.
• Coordinate patient transitions from acute/post-acute to home or other facilities.
• Collaborate with physicians, nursing staff, and other care team members to remove barriers to care.
• Monitor patient progress and ensure plans remain patient-centered and cost-effective.
• Coordinate diagnostic testing, discharge plans, and plan of care modifications.
• Ensure understanding of discharge instructions and follow-up needs.
• Coordinate post-discharge services including home health, hospice, DME, meds, and supplies.
• Schedule PCP or specialist follow-up within 7 days of discharge.
• Reconcile discharge meds and collaborate for medication review.
• Identify eligible patients for home health and other services.
• Obtain medical records from acute facilities and track readmissions.
• Participate in performance improvement initiatives and readmission reduction programs.
• Document activities accurately in the EMR and maintain coordination records.
• Apply Coleman Model transition-of-care principles.

Skills

Bilingual in English/Spanish

Excellent communication

Care coordination

Clinical assessment

EMR documentation

Problem-solving

Education

BSN (Bachelor’s degree in Nursing)

Tools

EMR

Job description

Company-Provided Equipment

We are seeking a fully bilingual English/Spanish RN Case Manager to support high-risk patients through chronic care management, transitions of care, and coordinated care planning.

This is a direct-hire, hybrid opportunity based in Tucson. The selected RN will typically work 2–3 days per week onsite at the center, with the remaining days working remotely. Specific onsite days are still being finalized.

The ideal candidate will have experience in case management, transitions of care, discharge planning, chronic care management, utilization management, or managed care, along with strong knowledge of post-acute care resources.

Key Responsibilities

• Oversee chronic care management and transitions of care for high-risk patients
• Serve as a clinical resource to multidisciplinary teams managing complex patients
• Complete comprehensive assessments addressing physical, mental, and social risk factors
• Develop and coordinate individualized care plans based on patient needs and identified barriers
• Perform telephone triage and appropriately address or elevate patient concerns
• Coordinate patient transitions from acute and post-acute settings to home or other transitional care facilities
• Collaborate with physicians, nursing staff, ancillary providers, and other members of the care team to remove barriers to appropriate care
• Coordinate patient care progression across the healthcare continuum
• Monitor patient progress and intervene as needed to ensure care plans remain patient-centered, high-quality, efficient, and cost-effective
• Coordinate diagnostic testing, treatment plans, discharge plans, and modifications to the plan of care
• Ensure patients and families understand discharge instructions, care plans, and follow-up needs
• Coordinate post-discharge services including home health, hospice, DME, medications, and other medical supplies
• Schedule patients for PCP or specialist follow-up within 7 days of discharge
• Reconcile discharge medications and collaborate with PCPs and clinical pharmacists for medication review
• Review patients for eligibility for home health and other transitional care services
• Obtain medical records from acute care facilities, including orders, referrals, diagnostic results, and care team documentation
• Track and monitor hospital readmissions and participate in initiatives designed to reduce avoidable readmissions and hospitalizations
• Identify at-risk populations using approved screening tools and follow established reporting procedures
• Coordinate with external case managers and community providers
• Refer appropriate patients for social work intervention
• Use clinical, financial, and patient-satisfaction data to identify opportunities for performance improvement
• Participate in clinical performance improvement initiatives and readmission reduction programs
• Document assessments, patient calls, and care coordination activities accurately and timely in the EMR
• Utilize conflict-resolution and problem-solving skills to address barriers to care
• Maintain knowledge of the Four Elements of the Coleman Model and apply transition-of-care principles

Required Qualifications

• Bachelor’s degree in Nursing (BSN)
• Fully bilingual in English and Spanish — REQUIRED
• Candidates must be able to communicate professionally and effectively in both English and Spanish
• Conversational Spanish alone does not meet the requirement
• Minimum 2 years of Registered Nurse experience
• Minimum 2 years of experience in one or more of the following:
• Case Management
• Chronic Care Management
• Transitions of Care
• Cost/Quality Management
• Managed Care or related clinical programs
• Working knowledge of chronic care management, discharge planning, utilization management, case management, and/or managed care reimbursement
• Knowledge of pre-acute and post-acute care settings and community resources
• Strong communication, organization, clinical assessment, and care coordination skills

Preferred Qualifications

• Experience with Medicare Advantage
• Experience in Value-Based Care
• Managed Care experience
• Experience working with high-risk or medically complex patient populations
• Experience with transitions-of-care and readmission reduction programs
• Experience coordinating home health, hospice, DME, and community-based services

Schedule & Work Arrangement

Monday–Friday | 8:00 AM–5:00 PM

Hybrid Schedule:

• Typically 2–3 days per week onsite at the Tucson center
• Remaining workdays are remote
• Specific required onsite days are currently being finalized