Nurse Case Manager: Transition & Discharge

United Hospital Center; Bridgeport (WV); On-site; USD 65,000 - 75,000; Full time

Job summary

United Hospital Center is seeking a skilled RN to plan targeted patient populations and manage resources for transition and discharge planning. You will work with the multidisciplinary care team to ensure timely, safe, and cost-effective transitions and referrals to post-acute services.

The role requires an active RN license and at least three years of clinical experience; BSN is preferred. The position emphasizes education for staff, physicians, patients, and families and ongoing collaboration

Qualifications

• RN license required in state of service or multi-state license via eNLC.
• Three years of clinical experience required.
• BSN preferred.

Responsibilities

• Manages all aspects of transition/discharge planning for assigned patients in a timely manner.
• Collaborates with the multidisciplinary team to facilitate transition/discharge for designated caseload.
• Monitors progress and ensures plan of care is patient-focused, high quality, efficient, and cost-effective.
• Provides education to staff, physicians, patients, and families for effective transition planning.
• Interacts directly with patient/family to assess needs and develop individual transition/discharge plan with physician input.
• Communicates with the team and post-acute providers about complex family dynamics affecting care and planning.
• Initiates referrals to post-acute services (Homecare, DME, Hospice, LTAC, Acute Rehab, SNF).
• Ensures documentation of transition/discharge activities per policy.
• Assists with patient power of attorney, surrogate, and advanced directives.

Skills

Discharge planning

Care coordination

Documentation

Education

RN license

BSN

Job description

United Hospital Center is seeking a skilled RN to plan targeted patient populations and manage resources for transition and discharge planning. You will work with the multidisciplinary care team to ensure timely, safe, and cost-effective transitions and referrals to post-acute services.

The role requires an active RN license and at least three years of clinical experience; BSN is preferred. The position emphasizes education for staff, physicians, patients, and families and ongoing collaboration