Discharge & Transitional Care Manager (RN)

AbsoluteCare; Cincinnati (AR); On-site; USD 68,000 - 102,000; Full time

Job summary

AbsoluteCare seeks a Transitional Care Manager to join the ICCT, coordinating in-person discharge planning, care transitions and integrated case management for members in inpatient facilities. The TCM works with hospital staff, AbsoluteCare physicians and community providers to ensure post-discharge needs are met and readmission risk is reduced.

Responsibilities include PCCP development, post-discharge calls, coordinating hospital follow-ups, and ensuring compliance with accreditation standards

Qualifications

• Licensed RN in the practicing state and in good standing.
• CCM or CCTM credentials preferred.
• 3+ years serving medically complex populations.
• Experience with discharge planning and care coordination.
• Proven ability to work with diverse community resources.
• Excellent written and spoken communication; proficient with EMR.

Responsibilities

• Meet with inpatient members to develop PCCP for discharge needs.
• Call members post-discharge to review instructions and reconcile meds.
• Coordinate post-discharge plans with PCPs, specialists, and home services.
• Communicate with AbsoluteCare team on discharge plans and barriers.
• Maintain PCCP and member contact per protocols and accreditation.
• Provide education using teach-back and patient-centered approaches.
• Attend clinical rounds and recommend next steps for care transitions.
• Meet established KPIs and manage caseload efficiently.

Skills

RN licensure

Discharge planning

Care coordination

CPR certification

Strong communication

Computer skills

Education

RN license

CCM credential

CCTM credential

CPR certification

Tools

EMR systems

Microsoft Office

Job description

AbsoluteCare seeks a Transitional Care Manager to join the ICCT, coordinating in-person discharge planning, care transitions and integrated case management for members in inpatient facilities. The TCM works with hospital staff, AbsoluteCare physicians and community providers to ensure post-discharge needs are met and readmission risk is reduced.

Responsibilities include PCCP development, post-discharge calls, coordinating hospital follow-ups, and ensuring compliance with accreditation standards