Senior Discharge & Care Transition Nurse

AbsoluteCARE Medical Center & Pharmacy; Cincinnati (OH); On-site; USD 75,000 - 105,000; Full time

Job summary

AbsoluteCare Medical Center & Pharmacy seeks a Transitional Care Manager (RN) to coordinate discharge planning and post-discharge care for members in the community. The role partners with inpatient facilities, the health plan, PCPs, specialists, and community resources to ensure seamless transitions and reduce readmissions.

Ideal candidates are RNs with CCM or CCTM credentials preferred, 3+ years' experience with complex populations, and strong communication and EMR skills.

Qualifications

• Licensed RN in the state of practice with CPR certification.
• CCM or CCTM credentials are preferred but not required.
• 3+ years serving medically complex populations in community settings.
• Experience with discharge planning, care transitions, and case management.

Responsibilities

• Meet with members during inpatient admission to develop a PCCP for discharge and transition needs.
• Call members post-discharge to review instructions, reconcile medications, and schedule follow-ups.
• Coordinate post-discharge plans with PCPs, specialists, home health, equipment, medications, and social supports.
• Communicate with AbsoluteCare team and community providers to review discharge plans and barriers to safe discharge.
• Attend clinical rounds with health plan partners and provide recommendations for appropriate level of care and next steps.

Skills

Communication skills

Clinical judgment

Travel readiness

Education

RN license

CPR certification

CCM or CCTM credentials

Tools

Electronic Medical Records (EMR)

Microsoft Office

Job description

AbsoluteCare Medical Center & Pharmacy seeks a Transitional Care Manager (RN) to coordinate discharge planning and post-discharge care for members in the community. The role partners with inpatient facilities, the health plan, PCPs, specialists, and community resources to ensure seamless transitions and reduce readmissions.

Ideal candidates are RNs with CCM or CCTM credentials preferred, 3+ years' experience with complex populations, and strong communication and EMR skills.