RN Care Manager: Transitional Care & Discharge Lead

McLaren; Lansing (MI); On-site; USD 70,000 - 95,000; Full time

Job summary

McLaren is seeking a Registered Nurse with strong care coordination skills to manage patient transitions across the continuum. The role emphasizes timely discharge planning, collaboration with physicians and social work, and reducing readmissions.

A minimum of three years in acute hospital care and Michigan RN licensure are required. The position entails coordinating with post-acute services, documenting in the EMR, and ensuring patient safety during transitions.

Qualifications

• RN licensure required in the state of Michigan.
• Bachelor’s degree in nursing from an accredited program; or pursuing degree with five years to obtain.
• Three years of acute hospital care experience.

Responsibilities

• Perform care coordination assessments for initial admission within 24 hours and for readmission planning.
• Collaborate with social work and disciplines to ensure safe, timely transitions to next level of care.
• Assess patient/family needs to reduce barriers to discharge and plan LOS.
• Identify unsigned LOC orders and coordinate with utilization management for orders.
• Review DRG/LOS data to inform discharge planning and identify point of contact.
• Assess readmission risk and initiate interventions to aid transition along the care continuum.
• Coordinate discharge planning referrals to social services, case management, and post-acute providers.
• Act as liaison among physician, patient, family, nursing and healthcare team.
• Document assessments, plans, interventions, barriers, and reassessments in EMR to facilitate discharges.
• Identify and report barriers and delays from the care plan to leadership.
• Represent the care management department on teams and outcomes committees.
• Ensure follow-up PCP appointments are arranged before discharge.
• Maintain operations by following policies and procedures.
• Perform other related duties as required.

Education

Bachelor's degree in nursing

RN licensure

Job description

McLaren is seeking a Registered Nurse with strong care coordination skills to manage patient transitions across the continuum. The role emphasizes timely discharge planning, collaboration with physicians and social work, and reducing readmissions.

A minimum of three years in acute hospital care and Michigan RN licensure are required. The position entails coordinating with post-acute services, documenting in the EMR, and ensuring patient safety during transitions.