Case Management RN — Transition of Care Leader

Sanitas Medical Centers; Lake Worth (TX); On-site; USD 65,000 - 85,000; Full time

Job summary

Sanitas Medical Centers is seeking a Case Management RN to oversee the transition of care for post-discharge and chronic condition patients. You will coordinate follow-up, develop personalized care plans, and educate patients to prevent readmissions and improve health outcomes.

Responsibilities include timely post-discharge outreach, coordinating with providers and home health agencies, implementing care plans, and documenting interactions in the care management platform in compliance with

Qualifications

• RN with responsibility for transition of care
• Coordinate follow-up with PCPs, specialists, home health
• Educate patients and caregivers on self-management
• Document interactions in care management platform per guidelines

Responsibilities

• Post-discharge outreach within 24-72 hours to assess needs and gaps in care
• Coordinate follow-up appointments and post-acute services with providers and community resources
• Develop and implement individualized care plans for chronic conditions
• Educate members and caregivers using motivational interviewing techniques
• Document all interactions and interventions in the care management platform per policy

Skills

Care coordination

Post-discharge follow-up

Patient education

Motivational interviewing

Clinical documentation

Tools

Care management platform

Job description

Sanitas Medical Centers is seeking a Case Management RN to oversee the transition of care for post-discharge and chronic condition patients. You will coordinate follow-up, develop personalized care plans, and educate patients to prevent readmissions and improve health outcomes.

Responsibilities include timely post-discharge outreach, coordinating with providers and home health agencies, implementing care plans, and documenting interactions in the care management platform in compliance with