RN Case Manager: Transitions of Care Lead

Central Health; Austin (TX); On-site; USD 70,000 - 95,000; Full time

Job summary

Central Health in Austin, TX seeks a Registered Nurse Case Manager - Transitions of Care to lead care coordination for patients with complex medical needs across hospital, home health and community settings.

This onsite role requires deep clinical expertise, collaboration with a multidisciplinary team, and a focus on reducing readmissions and addressing social determinants of health through evidence-based care planning.

Qualifications

• Graduation from an accredited School of Nursing with an ADN – Required.
• 3 years clinical nursing experience in hospital, home health, or ambulatory setting – Required.
• 2 years case management experience – Required.
• 1 year experience managing populations with complex medical needs – Required.
• Current unrestricted RN license in Texas – Required.
• Basic Life Support (BLS) – Required.
• Driver's license – Required.
• CCM – Preferred.
• ACM – Preferred

Responsibilities

• Lead care coordination for patients with complex conditions across inpatient, outpatient and community settings.
• Perform in-person and remote assessments, develop individualized care plans with measurable goals.
• Coordinate care across medical, behavioral health, social services, and community partners.
• Educate patients on disease management, medications, and self-care.
• Oversee medication management and reconciliation for PCP-prescribed meds.
• Promote culturally responsive, patient-centered care and shared decision-making.
• Utilize EHR and population health tools to track outcomes and support quality improvement.
• Act as clinical lead for the case management team and mentor staff and students.

Skills

Complex medical conditions

Interdisciplinary collaboration

Communication skills

Cultural humility

Relationship building

Attention to detail

EMR/EHR proficiency

Education

ADN from an accredited School of Nursing

Tools

EMR/EHR systems

Job description

Central Health in Austin, TX seeks a Registered Nurse Case Manager - Transitions of Care to lead care coordination for patients with complex medical needs across hospital, home health and community settings.

This onsite role requires deep clinical expertise, collaboration with a multidisciplinary team, and a focus on reducing readmissions and addressing social determinants of health through evidence-based care planning.