Transition of Care RN Case Manager

Cynet Health; Melville (NY); On-site; USD 55,000 - 83,000; Full time

Job summary

Cynet Health is seeking an RN - Case Manager for a 13-week assignment in the United States. The role requires an active RN license, a Bachelor’s degree, and at least 3 years of ambulatory experience, with Epic experience preferred. Shift is Day, 8 hours (08:00 - 16:00).

The Transitional Care Management RN coordinates care transitions after discharge, collaborating with providers, patients, caregivers, and community resources to reduce readmissions and ensure timely follow-up care.

Qualifications

• Bachelor’s Degree required.
• Minimum 3 years of ambulatory experience preferred.
• Epic experience preferred.

Responsibilities

• Conduct outreach to discharged patients within required timeframes (within 48 business hours).
• Complete comprehensive post-discharge assessments including medication reconciliation and discharge instruction review.
• Coordinate and schedule timely follow-up appointments with PCPs and specialists.
• Ensure completion of TCM documentation in the EHR.
• Monitor high-risk patients for complications or readmission risk.
• Escalate clinical concerns to providers promptly.
• Assess social determinants of health.
• Collaborate with physicians, nurses, social workers, and care managers to ensure continuity of care.
• Facilitate referrals for home care, behavioral health, or community resources.
• Assist patients and caregivers in understanding diagnoses, medications, and self-management strategies.

Skills

Case management

Ambulatory nursing

Post-discharge coordination

Epic experience

Education

Bachelor’s Degree

Tools

Epic

Job description

Cynet Health is seeking an RN - Case Manager for a 13-week assignment in the United States. The role requires an active RN license, a Bachelor’s degree, and at least 3 years of ambulatory experience, with Epic experience preferred. Shift is Day, 8 hours (08:00 - 16:00).

The Transitional Care Management RN coordinates care transitions after discharge, collaborating with providers, patients, caregivers, and community resources to reduce readmissions and ensure timely follow-up care.