Discharge & Care Transitions Nurse (RN) – Community-Based

AbsoluteCARE Medical Center & Pharmacy; Cincinnati (OH); On-site; USD 72,000 - 95,000; Full time

Job summary

AbsoluteCare Medical Center & Pharmacy seeks a Transitional Care Manager to lead discharge planning and post-discharge care coordination. Inpatient engagement followed by community-based management aims to optimize transitions and reduce readmissions.

You will coordinate with inpatient facilities, the health plan, PCPs and specialists, leveraging community resources to meet each member’s post-discharge needs. Strong clinical judgment and communication are essential.

Qualifications

• Must be a licensed RN in the practicing state.
• 3+ years serving complex populations in community settings.
• Experience with discharge planning, care coordination and case management.
• CPR certification required; CCM/CCTM a plus.

Responsibilities

• Meet patients during inpatient stay and develop PCCP.
• Call post-discharge to review instructions and reconcile meds.
• Coordinate post-discharge plans with PCPs, specialists, and home health.
• Communicate with AbsoluteCare team on discharge plans and barriers.
• Maintain PCCP documentation in line with protocols and standards.
• Provide education using teach-back methods and behavioral change techniques.
• Attend rounds with health plan partners and propose appropriate levels of care.
• Meet established performance indicators and manage caseloads.
• Mitigate barriers to care to reduce readmissions.

Skills

RN license

Travel (80%)

CPR certification

CCM/CCTM credential

EMR proficiency

Communication skills

Care transitions

Quality/compliance awareness

Driver's license

Second language

Education

RN degree

Tools

Microsoft Office

EMR systems

Job description

AbsoluteCare Medical Center & Pharmacy seeks a Transitional Care Manager to lead discharge planning and post-discharge care coordination. Inpatient engagement followed by community-based management aims to optimize transitions and reduce readmissions.

You will coordinate with inpatient facilities, the health plan, PCPs and specialists, leveraging community resources to meet each member’s post-discharge needs. Strong clinical judgment and communication are essential.