Senior Complex Care Transitions Manager (RN/LMSW)

HonorHealth; Arizona; On-site; USD 85,000 - 110,000; Full time

Benefits offered by this job

Sign-on bonus up to $10,000

Job summary

HonorHealth in Scottsdale, AZ is seeking a Complex and Transitional Care Manager to oversee care for high-risk, medically complex patients across the continuum. You will coordinate transitions, develop care plans, and partner with PCPs and embedded care coordinators.

The role emphasizes post-discharge follow-ups, chronic disease management, quality improvement, and ongoing education to staff. RN licensure, BLS, and regulatory requirements are expected.

Qualifications

• RN license required by state or compact.
• Minimum 2 years as Case Manager or Nurse Advocate.
• BLS certification required.
• Fingerprint Clearance Card required.

Responsibilities

• Coordinate patient transitions between hospitals, SNFs, home health, PCP, and specialists.
• Conduct timely post-discharge follow-ups via calls or in-home visits.
• Facilitate patient/caregiver education at transitions and chronic care management.
• Develop and implement care and transition plans with patient/caregiver, PCP, and embedded Care Coordinators.
• Monitor progress toward goals and advocate for access to services.
• Document assessments, care plans, and interventions in the EMR accurately.
• Collaborate with the Chief Medical Officer, providers, and other health professionals to coordinate complex outpatient care.
• Participate in quality improvement initiatives related to care transitions and chronic disease management.

Skills

Care coordination

Transition of care

Patient education

Mentoring

Education

Bachelor's in Nursing

Master's in Nursing preferred

Tools

EMR systems

Job description

HonorHealth in Scottsdale, AZ is seeking a Complex and Transitional Care Manager to oversee care for high-risk, medically complex patients across the continuum. You will coordinate transitions, develop care plans, and partner with PCPs and embedded care coordinators.

The role emphasizes post-discharge follow-ups, chronic disease management, quality improvement, and ongoing education to staff. RN licensure, BLS, and regulatory requirements are expected.