Transitional Care RN: Care Coordination & Discharge

Trinity Health MI; Muskegon (MI); On-site; USD 75,000 - 97,000; Full time

Job summary

Trinity Health MI is seeking a Registered Nurse Care Manager for a Grand Rapids hospital-based role with day shift and full-time hours. The incumbent will assess high-risk members, develop and implement outcome-based care plans, and coordinate with physicians and the care team to ensure smooth transitions and prevent readmissions.

The role requires a BSN, Michigan RN license, BLS, and at least three years of acute care or case management experience, with a preference for utilization or HMO

Qualifications

• Graduation from an accredited BSN Program.
• Current Michigan RN license.
• BLS certification.
• Valid Michigan Driver’s license.
• Three years acute care or case management experience.
• Preferred: Two years of utilization or HMO experience.

Responsibilities

• Keeps member/family members or other customers informed and requests further assistance when needed.
• Functions as liaison between administration, members, physicians and other healthcare providers.
• Performs a Health Risk Assessment (HRA) of the member and determines an acuity score for necessary scheduled follow‑ups.
• Develops an outcome‑based plan of care, based on the member’s input and assessed member needs. Implements and evaluates the plan of care as often as needed as evidenced by documentation in the member’s case file.
• Documents member assessment and reassessment, member care plans, and other pertinent information completed in the member’s medical record in accordance with Trinity Health Alliance of MI charting methodology, nursing standards, and company policies and procedures.
• Initiates onsite hospital visits/rounds as needed to assess patient progress and meet with appropriate members of the patient care team.

Skills

Driver's license

Education

BSN degree

Michigan RN license

BLS certification

Job description

Trinity Health MI is seeking a Registered Nurse Care Manager for a Grand Rapids hospital-based role with day shift and full-time hours. The incumbent will assess high-risk members, develop and implement outcome-based care plans, and coordinate with physicians and the care team to ensure smooth transitions and prevent readmissions.

The role requires a BSN, Michigan RN license, BLS, and at least three years of acute care or case management experience, with a preference for utilization or HMO