Senior Complex & Transitional Care Manager (RN/LMSW)

HonorHealth; Scottsdale (AZ); On-site; USD 75,000 - 110,000; Full time

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, including transitions from hospital to home.

The role emphasizes reducing readmissions, coordinating transitions among hospitals, SNFs, home health, and primary care, and developing individualized care plans with the care team. RN licensure and BLS are required; Master's degree preferred.

Qualifications

• Bachelor of Science in Nursing is required.
• Master of Science in Nursing is preferred.
• RN license and BLS certification are required.

Responsibilities

• Coordinate patient transitions between hospitals, SNFs, home health, primary care and specialists.
• Conduct post-discharge follow-ups via telephonic calls or in-home visits.
• Develop and implement individualized care plans with patient/caregiver and PCP.
• Monitor progress toward goals and adjust care plans as needed.
• Document assessments and interventions in the EMR accurately and timely.
• Collaborate with care team to coordinate complex outpatient care across the continuum.
• Participate in quality improvement initiatives related to care transitions and chronic disease management.

Education

Bachelor of Science in Nursing

Master of Science in Nursing

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, including transitions from hospital to home.

The role emphasizes reducing readmissions, coordinating transitions among hospitals, SNFs, home health, and primary care, and developing individualized care plans with the care team. RN licensure and BLS are required; Master's degree preferred.