RN Transitional Care & Discharge Manager

AbsoluteCARE Medical Center & Pharmacy; Baltimore (MD); On-site; USD 85,000 - 90,000; Full time

Job summary

AbsoluteCare Medical Center & Pharmacy in Baltimore, MD, seeks a Transitional Care Manager (RN) to join the Integrated Community Care Team. You will perform discharge planning, care coordination, and post-discharge support for patients admitted to inpatient facilities, coordinating with providers, health plans, and community resources.

You will review PCCP, conduct medication reconciliation, arrange follow-up care, and monitor outcomes.

Qualifications

• Licensed RN in the state of practice.
• Experience in discharge planning, care transition coordination and medical/behavioral case management.
• Ability to work with complex populations in community settings.

Responsibilities

• Meet with members during inpatient admission and develop PCCP for discharge needs.
• Call members post-discharge to review instructions and schedule follow-ups.
• Coordinate post-discharge plans with PCPs, specialists, and community services.
• Communicate with AbsoluteCare team and providers on discharge plans and barriers.
• Manage PCCP and member contact per agency requirements and accreditation standards.
• Provide education and trauma-informed, motivational interviewing-based interventions.

Skills

Discharge planning

Care coordination

Clinical judgment

Communication

Interdisciplinary teamwork

Education

Registered Nurse (RN) license

CCM or CCTM credentials a plus

Tools

Microsoft Office Suite

EMR documentation

Job description

AbsoluteCare Medical Center & Pharmacy in Baltimore, MD, seeks a Transitional Care Manager (RN) to join the Integrated Community Care Team. You will perform discharge planning, care coordination, and post-discharge support for patients admitted to inpatient facilities, coordinating with providers, health plans, and community resources.

You will review PCCP, conduct medication reconciliation, arrange follow-up care, and monitor outcomes.