Transitional Care RN — Discharge & Care Coordination

Absolutecare; Dayton (OH); On-site; USD 70,000 - 95,000; Full time

Job summary

AbsoluteCare seeks a Transitional Care Manager (TCM) to join the integrated community care team. This role focuses on in-person discharge planning, care coordination, and integrated case management for inpatients transitioning to community settings.

The TCM collaborates with inpatient facilities, the health plan, and primary care providers to ensure smooth transitions, reduce readmissions, and meet patient-specific post-discharge needs.

Qualifications

• Must hold RN license in the state of practice.
• 3+ years serving complex populations in community or office settings.
• CCM or CCTM credentials a plus.

Responsibilities

• Meet with members during inpatient admission to develop PCCP for discharge and care transition.
• Call members post-discharge to review instructions and schedule follow-up visits.
• Coordinate post-discharge plans with PCPs, specialists, home health, equipment, medications, and social supports.
• Communicate with AbsoluteCare team and providers to review discharge plans and barriers to safe discharge.
• Maintain PCCP and member contact per agency requirements and accreditation standards.
• Provide education using teach-back on medical, behavioral, and functional health conditions.

Skills

Discharge planning

Care coordination

Case management

Travel up to 80%

Effective communication

Education

Registered Nurse (RN) license

Tools

EMR documentation

Microsoft Office

Job description

AbsoluteCare seeks a Transitional Care Manager (TCM) to join the integrated community care team. This role focuses on in-person discharge planning, care coordination, and integrated case management for inpatients transitioning to community settings.

The TCM collaborates with inpatient facilities, the health plan, and primary care providers to ensure smooth transitions, reduce readmissions, and meet patient-specific post-discharge needs.