Discharge & Care Transitions Lead

AbsoluteCare; Columbus (OH); On-site; USD 65,000 - 90,000; Full time

Job summary

AbsoluteCare in Ohio is seeking a Transitions of Care Manager (RN) to provide in-person discharge planning, care coordination, and integrated case management for members admitted to facilities. You’ll work with inpatient teams, PCPs, specialists, and community resources to meet post-discharge needs and improve outcomes.

The role requires 3+ years of experience with complex populations, strong communication, and proficiency in EMR systems.

Qualifications

• Licensed RN with active state license
• 3+ years serving complex populations in community or inpatient settings
• Experience in discharge planning and transitions of care

Responsibilities

• Meet with members during inpatient admission to develop PCCP
• Call members post-discharge to review instructions and schedule follow-ups
• Coordinate post-discharge plans with PCPs, specialists, home health and equipment
• Communicate with AbsoluteCare team and providers on discharge plans
• Manage PCCP and member contacts per agency requirements
• Provide education using teach-back methods on health conditions and treatment options
• Attend clinical rounds to review PCCPs and next steps
• Meet established performance indicators and manage caseloads

Skills

RN license

Care coordination

Discharge planning

Communication skills

EMR proficiency

Education

Registered Nurse license (OH)

Tools

EMR systems

Job description

AbsoluteCare in Ohio is seeking a Transitions of Care Manager (RN) to provide in-person discharge planning, care coordination, and integrated case management for members admitted to facilities. You’ll work with inpatient teams, PCPs, specialists, and community resources to meet post-discharge needs and improve outcomes.

The role requires 3+ years of experience with complex populations, strong communication, and proficiency in EMR systems.