Onsite Inpatient Care Transition Specialist (RN/LPN)

MaxHealth; Florida; On-site; USD 60,000 - 90,000; Full time

Benefits offered by this job

Hiring bonus $500 after 30 days

Job summary

MaxHealth in Lakewood Ranch, FL is seeking an Onsite Inpatient Case Manager to coordinate care transitions for patients after ED visits, hospital stays, or skilled nursing facility discharges. This role works onsite with clinical teams to reduce readmissions and improve patient experience.

Responsibilities include face-to-face visits, developing individualized transition plans, arranging follow-up appointments within 3 days, coordinating medications, and maintaining accurate EHR documentation.

Qualifications

• Active RN or LPN license required.
• Minimum 3 years of clinical or case management experience.
• Experience with care transitions, population health, or chronic disease management preferred.

Responsibilities

• Conduct face-to-face or bedside visits with patients and care team prior to discharge.
• Develop and implement individualized transitional care plans with providers and caregivers.
• Ensure timely post-discharge follow-up appointments within 3 days.
• Coordinate medication reconciliation and education with pharmacy or nursing staff.
• Identify and address social determinants affecting recovery.
• Monitor progress during 30-day post-discharge period with outreach and coordination.
• Maintain documentation in the EHR according to standards.
• Track outcomes such as readmissions and follow-up adherence using population health tools.
• Serve as liaison between inpatient and outpatient teams for continuity of care.

Skills

Case management

Care transitions

EHR / EMR systems

Organization

Problem solving

Education

Active RN or LPN license

3 years clinical or case management

Tools

EMR / EHR systems

Job description

MaxHealth in Lakewood Ranch, FL is seeking an Onsite Inpatient Case Manager to coordinate care transitions for patients after ED visits, hospital stays, or skilled nursing facility discharges. This role works onsite with clinical teams to reduce readmissions and improve patient experience.

Responsibilities include face-to-face visits, developing individualized transition plans, arranging follow-up appointments within 3 days, coordinating medications, and maintaining accurate EHR documentation.