RN: Transitions of Care & Discharge Coordinator

AbsoluteCARE Medical Center & Pharmacy; Columbus (OH); Vor Ort; USD 70.000 - 90.000; Vollzeit

Zusammenfassung

AbsoluteCARE Medical Center & Pharmacy is seeking an experienced Registered Nurse to join the Integrated Community Care Team (ICCT) as a Transitional Care Manager. You will coordinate discharge planning, in-person care transitions, and post-discharge follow-up for high-need members in the Columbus area.

The role emphasizes collaboration with inpatient facilities, health plans, PCPs, specialists, and community resources to reduce readmission risk and improve outcomes.

Qualifikationen

• Willingness to travel up to 80% to local hospitals, SNFs, and residential treatment facilities.
• Licensed RN in the state of practice and compliant with laws and requirements.
• 3+ years serving medically complex populations in office or community settings.
• Discharge planning and care coordination experience to ensure smooth transitions.
• Familiarity with complex government-sponsored populations (Medicare/Medicaid) preferred.
• Experience with concurrent review for level of care determinations; knowledge of MCG/ASAM a plus.
• Strong problem-solving abilities and proactive barrier resolution for transitions of care.
• Proficient in Microsoft Office and EMR documentation; excellent written and verbal communication.
• Ability to meet accreditation standards (NCQA, PCMH, HEDIS) through defined processes.
• Ability to work independently with sound clinical judgement; valid driver’s license and reliable transportation.
• Second language skills are desirable depending on local population.

Aufgaben

• Meet with inpatients and develop person-centered care plans to address discharge needs.
• Call members post-discharge to review instructions and reconcile medications.
• Coordinate post-discharge plans with PCPs, specialists, home health, and community services.
• Communicate with AbsoluteCare and community PCPs to review discharge plans and barriers.
• Maintain PCCP records in compliance with agency requirements and accreditation standards.
• Provide education using teach-back methods on health conditions and treatment options.
• Attend clinical rounds and provide recommendations for appropriate level of care.

Kenntnisse

Discharge planning

Care coordination

Case management

Communication skills

Travel readiness

Ausbildung

RN License (Ohio)

Tools

EMR documentation

Jobbeschreibung

AbsoluteCARE Medical Center & Pharmacy is seeking an experienced Registered Nurse to join the Integrated Community Care Team (ICCT) as a Transitional Care Manager. You will coordinate discharge planning, in-person care transitions, and post-discharge follow-up for high-need members in the Columbus area.

The role emphasizes collaboration with inpatient facilities, health plans, PCPs, specialists, and community resources to reduce readmission risk and improve outcomes.