Registered Nurse / LMSW - Complex & Transitional Care Manager II (ICP)

74 Innovation Care Partners; United States; On-site; USD 90,000 - 120,000; Full time

Job summary

HonorHealth is seeking a Complex and Transitional Care Manager in Scottsdale, AZ. This role focuses on high-risk, medically complex patients, coordinating transitions across hospital, SNF, home health, and primary care.

You will develop individualized care plans and monitor progress, collaborating with physicians and embedded care coordinators to ensure safe, patient-centered care. Ideal candidates have 2+ years as a care manager or transitional care manager and an RN license; a Master's degree

Qualifications

• 2 years as Case/Care Manager or Transitional Care Manager required.
• 3 years Registered Nurse preferred.
• Bachelor's Nursing required; Master's preferred.

Responsibilities

• Coordinate patient transitions between hospitals, SNFs, home health, PCP and specialists.
• Conduct post-discharge follow-ups via phone or in-home visits.
• Develop and implement individualized care and transition plans with patients and care teams.
• Document assessments and care plans in the EMR accurately and timely.
• Support quality improvement in care transitions and chronic disease management.

Skills

Care Management

Transition of Care

RN

Education

Bachelor's Nursing

Master's Nursing

Job description

Primary City/State: Innovation Care Partners - 8901 E Mountain View Rd Scottsdale, AZ 85258 Category: Case Management Shift: Day Department: Care Management Up to 10,000.00 Sign On Bonus Available 8:00 - 4:30

Great care starts with great people. (Like you.) At HonorHealth, you’ll find something special. From humble beginnings in 1927 to one of Arizona’s largest nonprofit healthcare systems, our culture is built on warmth and neighborly kindness. Behind every smile is a highly skilled professional with deep expertise and an unwavering dedication to what matters most — caring for the health and well-being of people and communities across the greater Phoenix area.

Responsibilities

JOB SUMMARY The Complex and Transitional Care Manager is responsible for managing the care of high-risk, medically complex patients throughout the continuum of care. This includes both chronic condition management and transitional support during care transitions (e.g., hospital discharge, rehab, home care). The goal is to improve clinical outcomes, reduce avoidable readmissions, and support safe, patient-centered care.

ESSENTIAL FUNCTIONS

Coordinate patient transitions between hospitals, skilled nursing facilities (SNFs), home health, primary care, and specialists. Conduct timely patient post-discharge follow-ups via telephonic calls or in-home visits, as warranted. Facilitate patient/caregiver education at transitions of care and chronic care management. Develop and implement individualized care plans and transition plans in collaboration with patient/caregiver, PCP and embedded Care Coordinators. Monitor progress toward goals, adjust care plans as needed, and advocate for access to appropriate services. Document assessments, care plans, and interventions in the electronic medical record (EMR) accurately and in a timely manner. Collaborate with the Chief Medical Officer, providers, primary care, embedded Care Coordinators and other health care professionals/agencies to ensure complex outpatient care is coordinated across the health care continuum Participate in quality improvement initiative related to care transitions, chronic disease management, and utilization reduction. Mentors as a buddy for new Care Mangers and Care Coordinators. Is key in developing PCP and embedded Care Coordinator relationships and education on Care Management program. Maintain all regulatory educational requirements by participating in continuing education activities. Demonstrate professional behavior and promotes cooperation and team building. Maintain and manage to their caseload Support and participate in the development and maintenance of scorecard. Maintain accurate metric tracking for daily productivity management. Perform other duties or responsibilities as assigned by people leader to meet business needs.

Education

Bachelors Nursing Required Masters Nursing Preferred

Experience

2 years as Case (or Care) Manager, Transitional Care Manager, Care Coordinator RN or Nurse Advocate Required 3 years Registered Nurse Preferred

LICENSE AND CERTIFICATIONS

Registered Nurse (RN) - License State And /Or Compact State Licensure Required Basic Life Support (BLS) - Certification Required Fingerprint Clearance Card (FPC) - Certificate Required Certified Case Manager - Certification Preferred or Accredited Case Manager (ACM) - Certification Preferred Certification in Healthcare - nursing or other healthcare field Preferred

We're all in for your career. Expert care from experts who care. At HonorHealth, you’ll find something special. Our culture is built on warmth and neighborly kindness, but behind every smile is a highly skilled professional with deep expertise and unwavering dedication. We’re delivering a healthcare experience that simply feels better through:

• Nine acute-care hospitals
• Over 200 primary, specialty and urgent care centers
• More than 17,000 team members and 4,000 medical staff

Since 1927, we’ve been focused on doing what matters most — caring for people and communities across the greater Phoenix area. From humble beginnings to one of Arizona’s largest nonprofit healthcare systems, we’re just as driven as we were a century ago. Come join us and go all in for your career.

IMPORTANT: HonorHealth is committed to providing an excellent candidate experience for candidates interested in our job opportunities. We also care about the online safety of our job seekers. Please note the following: HonorHealth employee emails come from HonorHealth (i.e [e-mail]) not a generic email address, such as gmail or yahoo. If you are suspicious of a job posting, or if you receive any email from an HonorHealth employee that you believe to be fictitious, please contact us [e-mail]. HonorHealth does not use Google Hangouts to conduct interviews or conversations. HonorHealth will not ask you to provide any personal information (i.e. drivers license, bank account, credit card information, passwords, social security number) outside of our Applicant Tracking Software before a job offer is extended. If you believe that HonorHealth has violated your civil rights or believe you have experienced discrimination, please click the link to obtain information on your rights to file a complaint. For more information, please click here.