Complex & Transitional Care Manager II (RN/LMSW)

HonorHealth; Scottsdale (AZ); On-site; USD 85,000 - 110,000; Full time

Job summary

HonorHealth in Scottsdale, AZ seeks a Complex and Transitional Care Manager to oversee care for high-risk, medically complex patients across the continuum. The role focuses on reducing readmissions and supporting safe, patient-centered transitions from hospital to home or rehab.

Responsibilities include coordinating transitions, post-discharge follow-ups, patient/caregiver education, and developing individualized care plans with PCPs and embedded coordinators.

Qualifications

• Bachelor's in Nursing required.
• RN license required.
• BLS required.
• Fingerprint Clearance Card required.

Responsibilities

• Coordinate patient transitions between hospitals, SNFs, home health, primary care, and specialists.
• Conduct timely post-discharge follow-ups via telephonic calls or in-home visits.
• Facilitate patient/caregiver education at transitions of care and chronic care management.
• Develop and implement individualized care plans and transition plans with patient/caregiver, PCP and embedded Care Coordinators.
• Monitor progress toward goals, adjust care plans as needed, and advocate for access to appropriate services.
• Document assessments, care plans, and interventions in the EMR accurately and timely.

Education

Bachelor's in Nursing

Master's in Nursing

Job description

HonorHealth in Scottsdale, AZ seeks a Complex and Transitional Care Manager to oversee care for high-risk, medically complex patients across the continuum. The role focuses on reducing readmissions and supporting safe, patient-centered transitions from hospital to home or rehab.

Responsibilities include coordinating transitions, post-discharge follow-ups, patient/caregiver education, and developing individualized care plans with PCPs and embedded coordinators.