RN Care Manager: Discharge & Transition Specialist

McLaren Health Care; Port Huron (MI); On-site; USD 70,000 - 95,000; Full time

Job summary

McLaren Health Care is seeking a Case Management RN to coordinate and transition patients to appropriate levels of care. The role collaborates with physicians, nursing, and home care teams to reduce readmissions and control costs.

Responsibilities include initial assessments within 24 hours of admission, discharge planning, and coordinating referrals to social services and post-acute care as part of a multidisciplinary team.

Qualifications

• RN licensure is required across the state.
• Bachelor’s degree in nursing or actively pursuing degree to be obtained within five years of accepting position.
• Three years of acute hospital care experience are required.

Responsibilities

• Performs care coordination assessments for initial patient assessment within 24 hours of admission.
• Collaborates with social worker and disciplines to ensure safe, timely transition to next level of care.
• Assesses patient/family needs to reduce barriers and formulate discharge plans.
• Identifies unsigned level of care orders and communicates with utilization management.
• Reviews current DRG/LOS to assess discharge planning needs with providers.
• Assesses readmission risk and initiates interventions to support transition.
• Performs discharge planning coordination/referral to social services and other agencies per SOP.

Skills

Nursing patient care

Care coordination

Interdisciplinary collaboration

Education

Bachelor’s degree in nursing

Pursuing BSN within five years

Tools

Cerner

Job description

McLaren Health Care is seeking a Case Management RN to coordinate and transition patients to appropriate levels of care. The role collaborates with physicians, nursing, and home care teams to reduce readmissions and control costs.

Responsibilities include initial assessments within 24 hours of admission, discharge planning, and coordinating referrals to social services and post-acute care as part of a multidisciplinary team.