Senior Discharge & Transitional Care Manager

AbsoluteCare; Washington, Baltimore (District of Columbia, MD); Presencial; USD 81.000 - 99.000; Jornada completa

Descripción de la vacante

AbsoluteCare in Washington, DC is seeking a Transitional Care Manager to join the Integrated Community Care Team (ICCT). The role focuses on in-person discharge planning, care coordination, and integrated case management for members in inpatient facilities, coordinating with hospital staff, primary care providers, and community resources.

You will manage complex medical, behavioral, and social determinants of health needs, drive value-based outcomes, and ensure timely follow-up, with travel to

Formación

• Must be a licensed RN in the practicing state.
• Willing to travel up to 80% locally to facilities.
• 3+ years serving complex populations in community settings.
• CCM or CCTM credentials are a plus.
• Experience with discharge planning and transitions of care.

Responsabilidades

• Meet with members during inpatient admission to develop a PCCP for discharge needs.
• Call post-discharge to review instructions, reconcile meds, schedule follow-ups.
• Coordinate post-discharge plans with PCPs, specialists, and home health.
• Communicate with AbsoluteCare team and community providers on discharge plans.
• Manage PCCP and member contacts per agency protocols and standards.
• Provide education with teach-back on health conditions and options.
• Attend clinical rounds and offer recommendations for care levels.

Conocimientos

Communication skills

Discharge planning

Care coordination

Clinical judgment

EMR documentation

Educación

RN license

CCM/CCTM desirable

Herramientas

EMR system

MS Office Suite

Descripción del empleo

AbsoluteCare in Washington, DC is seeking a Transitional Care Manager to join the Integrated Community Care Team (ICCT). The role focuses on in-person discharge planning, care coordination, and integrated case management for members in inpatient facilities, coordinating with hospital staff, primary care providers, and community resources.

You will manage complex medical, behavioral, and social determinants of health needs, drive value-based outcomes, and ensure timely follow-up, with travel to