RN Case Manager: Care Coordination & Transitions Lead

Luminis Health; Annapolis (MD); On-site; USD 48,000 - 69,000; Full time

Benefits offered by this job

Medical, Dental, and Vision Insurance

Paid Time Off

Tuition Assistance Benefits

Employee Referral Bonus Program

Job summary

Luminis Health is seeking a Case Manager to coordinate care for patients across the continuum under the clinical director of care management. Using quantitative and qualitative methods, you will assess, plan, implement and evaluate services to meet each patient’s health and social needs, including social determinants, ensuring timely transitions and appropriate level of care.

Responsibilities include using motivational interviewing, applying evidence-based guidelines, documenting in Epic, and

Qualifications

• BSN or ADN with equivalent experience; BSN must be achieved within 5 years.
• Three years of experience in a clinical setting, ambulatory or post-acute.
• Current licensure as a registered nurse by the Maryland Board of Nursing.

Responsibilities

• Identify and prioritize patients needing care management using holistic biopsychosocial factors.
• Utilize motivational interviewing to promote engagement and adherence to treatment.
• Apply InterQual or other evidence-based guidelines to determine level of care.
• Manage observation stay patients and coordinate transitions to inpatient status or discharge.
• Develop and coordinate transition plans for home health, hospice, post-acute providers.
• Maintain clear documentation reflecting patient status and transition needs.
• Participate in clinical outcome projects and care management process improvements.
• Refer to other health care team members as needed and monitor follow-up.

Skills

Care coordination

Motivational interviewing

Evidence-based guidelines

Epic documentation

Education

BSN or ADN with equivalent experience

Tools

Epic

Job description

Luminis Health is seeking a Case Manager to coordinate care for patients across the continuum under the clinical director of care management. Using quantitative and qualitative methods, you will assess, plan, implement and evaluate services to meet each patient’s health and social needs, including social determinants, ensuring timely transitions and appropriate level of care.

Responsibilities include using motivational interviewing, applying evidence-based guidelines, documenting in Epic, and