Discharge & Care Coordination Navigator

AbsoluteCARE; Cincinnati (OH); On-site; USD 70,000 - 90,000; Full time

Job summary

AbsoluteCARE Medical Center & Pharmacy is seeking a Transitional Care Manager (RN) to join the integrated community care team. You will partner with inpatient facilities, the health plan, and local providers to coordinate complex post-discharge care and ensure smooth transitions for medically complex patients.

The role emphasizes person-centered care planning, medication reconciliation, and adherence to accreditation standards.

Qualifications

• Requires RN license in practicing state and ability to travel locally up to 80% to hospitals and facilities.
• Experience with discharge planning, care transition coordination and medical/behavioral case management in the community.
• Experience with complex populations including Medicaid/Medicare beneficiaries.
• Proven ability to engage members and coordinate transitions of care across settings.
• Familiarity with NCQA/PCMH/HEDIS accreditation requirements is a plus.

Responsibilities

• Meet with members during inpatient admission to develop a PCCP for discharge and transition needs.
• Call members post-discharge to review instructions, reconcile meds, and schedule follow-up visits.
• Coordinate post-discharge plans with primary care, specialists, home health and community resources.
• Communicate with AbsoluteCare team and community providers to review discharge plans and barriers.
• Provide education on medical/behavioral conditions using teach-back methods.

Skills

Discharge planning

Care coordination

Stakeholder communication

Clinical judgment

Microsoft Office

Education

RN license (state)

CCM or CCTM credentials a plus

Job description

AbsoluteCARE Medical Center & Pharmacy is seeking a Transitional Care Manager (RN) to join the integrated community care team. You will partner with inpatient facilities, the health plan, and local providers to coordinate complex post-discharge care and ensure smooth transitions for medically complex patients.

The role emphasizes person-centered care planning, medication reconciliation, and adherence to accreditation standards.