Hybrid RN: Care Coordination & Transitions Specialist

Mascmedical; California (MO); Hybrid; USD 70,000 - 100,000; Full time

Benefits offered by this job

Medical benefits

Dental benefits

Vision benefits

401(k) plan

PTO 3 weeks

Job summary

Zohorecruit in Riverside, CA offers a hybrid Registered Nurse role focused on care coordination and enhanced care management. You will guide clinical decisions, support transitions of care, and collaborate with physicians, care teams, and community resources to improve outcomes for patients with complex needs.

The ideal candidate holds an active California RN license, has care coordination experience, and excels at patient engagement, documentation, and multidisciplinary teamwork.

Qualifications

• Active Registered Nurse license in California.
• Experience in care coordination, case management, population health, enhanced care management, or similar patient support programs.
• Strong understanding of clinical care planning, patient engagement, and care transitions.
• Knowledge of social determinants of health and community resource navigation.
• Ability to support patients with complex medical, behavioral, and social needs.

Responsibilities

• Serve as a clinical resource and subject matter expert for care coordination and enhanced care management programs.
• Provide care recommendations within the scope of the Registered Nurse license and under appropriate physician oversight.
• Support clinical assessments that contribute to individualized care plan development.
• Promote patient engagement, education, and follow-through with care plans.
• Conduct telephonic outreach and patient visits as needed based on program needs.
• Support transitions of care, including post-discharge follow-up and engagement with high-risk patients.
• Reinforce provider recommendations and care plans during patient interactions.
• Coordinate services such as primary care, specialty care, labs, durable medical equipment, behavioral health, and community-based resources.
• Assess environmental, social, and functional barriers to care and help coordinate appropriate interventions.
• Participate in multidisciplinary team meetings.
• Collaborate with leadership to support care model improvements.
• Identify and escalation clinical or social concerns to the appropriate team members.
• Perform chart audits in accordance with company, regulatory, and compliance standards.
• Maintain compliance with HIPAA, company policies, and documentation requirements.
• Perform other duties as assigned based on program and organizational needs.

Skills

Care coordination

Patient engagement

Clinical oversight

Communication

Documentation

Education

Registered Nurse license (CA)

Job description

Zohorecruit in Riverside, CA offers a hybrid Registered Nurse role focused on care coordination and enhanced care management. You will guide clinical decisions, support transitions of care, and collaborate with physicians, care teams, and community resources to improve outcomes for patients with complex needs.

The ideal candidate holds an active California RN license, has care coordination experience, and excels at patient engagement, documentation, and multidisciplinary teamwork.