Nurse Manager- Transitions of Care (Inpatient/TCAH)
Central Health
Transition Of Care Nurse ManagerThe Transition of Care Nurse Manager will be part of a holistic, collaborative, multidisciplinary team that will support the clients in the transitional program to ensure patients are connected to services and care, which is a team based model. The Nurse Manager is responsible for the development, performance and management of clinical patient care for the Transition of Care (TOC) team, including a nurse, social worker, and community health worker. The Nurse Manager will support the triad leadership team in making decisions that best support clinical staff, extended care team members and providers to ensure patients obtain access to care that is timely, effective, efficient, and safe.The Transition of Care Nurse Manager will also assist in assessing patients for placement to the program, visit and monitor program participants regularly and provide general nursing care as needed as defined by the Texas Board of Nursing. The RN practices professional nursing as defined by the Texas Board of Nursing, Texas Nurse Practice Act and by adhering to organizational policies, procedures, and guidelines. Our nurses are committed to providing a collaborative environment to provide the safest and highest quality of care for our patients. Our Leaders model a commitment to the organization's vision/mission/values to support an unparalleled patient experience and positive clinical outcomes.The Transition of Care Nurse Manager may work onsite at a primary location or multiple locations based on business and patient needsResponsibilitiesEssential Functions:Collaborates with the patient's care team including primary care team, specialists, home care, hospital team, and any others involved with the patient's care to optimize clinical outcomes.Performs regular analysis of key performance indicators to improve clinical care workflows that lead to improvement of the quality of patient care and enhance cost effectiveness.May conduct chart audits as needed to ensure adherence to workflows.Provides support to the site Triad management team to ensure the clinical services team supports the overall operational and fiscal activities of the site to include staffing levels, budgets, financial and operating goals such as productivity and quality.Responsible for interviewing/selecting candidates, approving payroll, time off requests, administering performance evaluations, training, and orientation of new hires, and for coaching and counseling staff.Manages the clinical support team.Establishes work assignments, implements, and provides oversight of clinical care delivered by licensed nursing staff and medical assistants.Ensures that patient care huddles are being conducted.Maintains positive, effective, and timely communication with partner and community organizations.Screen respite for appropriateness, educate patient regarding scope of services, respite facility guidelines. Consults with Respite Provider leadership as needed to determine appropriateness of level of care.Document status of referral, outreach attempts, etc. as per workflow in electronic medical record.Enhances the patient experience by addressing and resolving patient issues in a timely manner.Ensures all tasks provided and associated with patient care, patient administrative processes and related duties comply with all regulatory and accreditation standards, and Central Health Standard Operating Procedures, Policies and Procedures.Adheres to the Texas Board of Nursing and Texas Nurse Practice Act requirements and to other governing agency regulations.Participates in leadership activities such as serving on committees as assigned, participating in continuous quality improvement projects and organizational initiatives to promote and maintain a strong positive workplace culture.Assists in the development of departmental protocols, policies, and procedures.Coordinates and attends staff meetings and education offerings both in person and via teleconference/online as required.Performs other duties as assigned.Knowledge, Skills and Abilities:Sound-critical thinking and decision-making skills.Excellent customer service skills; excellent interpersonal/assertive communication skills demonstrating a high degree of emotional intelligence.Knowledge of social determinants of health issues and demonstrated sensitivity to underserved populations.Ability to communicate effectively with patients of various ages, educational and cultural backgrounds.Ability to communicate effectively with diverse community audiences.Skill in fostering and maintaining positive relationships with a number of community partners.Skill in triaging and ensuring appropriate level of care for patients in an accurate and efficient manner.Strong working knowledge of Microsoft Office Suite, SharePoint, and PowerPoint.QualificationsMinimum Requirements to be considered for role:Education:Graduation from an accredited school of nursing.Work Experience:Two years of clinical nursing leadership experience in a clinic, hospital, or related setting.Licenses and Certifications:RN - Registered Nurse - State Licensure and/or Compact State LicensureBasic Life Support - Obtained through approved American Heart Association
- Overview The Registered Nurse Case Manager - Transitions of Care is a clinically experienced registered nurse responsible forleading care coordination... ...a pivotal role in ensuring continuity of care across inpatient, outpatient, andcommunity environments. This is an onsite...SuggestedWork experience placementLive in
$56.2k - $101k
**Business Area:** Clinical & Care Management **Job Type:** Full time **Position Purpose:** Performs... ...and coordination teams to identify transition support services. **Key Details** :... ...a Degree from an Accredited School of Nursing and 2 - 4 years of related experience....SuggestedFull timePart timeWork at officeRemote workFlexible hours- Suvida Healthcareis seeking a Nurse Care Manager to join a multidisciplinary team delivering high-quality care to high-risk patients. You... ...coordinate chronic disease management, discharge planning, and transitions across care settings to optimize outcomes and resource use....Suggested
- Suvida Healthcare seeks a Nurse Care Manager to join a multidisciplinary team focused on high‑risk patients. You will develop care plans, manage transitions of care, and coordinate with providers to ensure high‑quality, cost‑effective services across our network. The role...Suggested
- Centene is seeking a Care Manager Transition of Care to assess, plan, and coordinate post-discharge services. This role focuses on behavioral health or nursing backgrounds to improve patient outcomes through effective care management. You will evaluate member needs, reconcile...SuggestedRemote job
- ...Director of Post Acute and Care at Home Programs, the Transitions of Care PhysicianLead... ...programs, includingSkilled Nursing Facilities (SNFs), Transitional Care at Home (TCAH), acute hospital settings,... ...APPs, Nurses, CHWs, case management, primary care providers, hospital...Full time
- Central Health in Austin, TX seeks a Registered Nurse Case Manager - Transitions of Care to lead care coordination for patients with complex medical needs across hospital, home health and community settings. This onsite role requires deep clinical expertise, collaboration...
- Central Health seeks an Associate Medical Director to lead post-acute and care-at-home transitions, overseeing TOC programs including SNFs, TCAH, and hospital-based care. The physician champion drives clinical operations, quality and safety, and provider engagement, partnering...
- ...deliver exceptional patient care. What Sets Us Apart?... ...team achievements. Care Transition Coordinator – Hospice Field... ...drive referral volume • Track, manage, and document sales activity... ...with hospitals, skilled nursing facilities, and physician offices...Full timeWork at officeFlexible hours
$33.99 - $63.22 per hour
...progression and level of care, and discharge plans... ...and ensure a timely transition, escalating care delays... ...planning needs in the inpatient, observation and/or emergency... ...[Required] Ability to manage multiple tasks and... ...: Associate's of Nursing [Required] Bachelor's...Full timeWork experience placementWork at officeLocal areaFlexible hoursShift work- ...Care Transition Manager RN – Care Management Bring your passion to Texas Health so we are Better + Together! Work location: Texas Health Dallas... ...balance for all Here’s What You Need Bachelor's Degree Nursing required (Individuals hired as CTRN prior to May 11, 2017,...Full timeMonday to Friday
$54.1k - $142.58k
...passionate colleagues who care deeply, innovate with... ...-Risk Maternity case management team and experience... ...functions as well as smooth transition to Aetna programs and... ...as an RN in an inpatient or outpatient setting... ...Associates Degree Nursing Bachelor's in Science...Hourly payFull timeTemporary workWork at officeLocal areaRemote workWork from homeMonday to Friday- As a Registered Nurse Case Manager, your voice to influence patient care is valued and empowered at every turn -whether... ...leaders, you will help ensure safe transitions, clear communication, and... ...hospital, offering a wide range of inpatient and outpatient services. The...Temporary workFlexible hoursWeekend work
$70k - $85k
A healthcare staffing agency is seeking a Bilingual Nurse Care Manager to oversee complex patient care. This role involves collaborating with providers and managing high-risk patients. Candidates require a Bachelor's in Nursing, an active RN license, and at least 2 years...Monday to Friday- ...Amerita is seeking a Clinical Educator in the Austin, TX area to guide patient education and transition planning for home and alternate-site infusion care. The role includes in-person and virtual training, coordination with clinical teams, and ongoing development of education...
- Texas Health Resources in Dallas, TX, is seeking a Care Transition Manager Social Worker (SW) to ensure timely, safe transitions of patients to appropriate levels of care. The role requires a Master’s in Social Work, active licensure, and experience in hospital-based social...
- Texas Health Resources seeks a Care Transition Manager Social Worker (LMSW/LCSW) for PRN coverage in Fort Worth, TX. The role supports hospital discharge planning, coordinates care transitions, and collaborates with the care team to ensure timely patient progression. The...ReliefShift workWeekend workWeekday work
$30 - $37 per hour
Join Our Team as a Nurse Care Manager! Remote opportunity for residents of Oregon, Washington,... ...continuity of care across settings (e.g., inpatient, outpatient, specialty, post-acute),... ...ambulatory care, care coordination, transitional care, or discharge planning preferred...Full timeWork at officeRemote workMonday to FridayShift work- Care Transition Manager SW (Social Worker) - Case Management Bring your passion to Texas Health so we are Better + Together! Work location: Texas Health Plano, 6200 West Parker Road, Plano TX 75093 Work hours: PRN - Flexible, M-F and weekends. 8a-5p. Two holidays per year...ReliefFlexible hoursWeekend work
- Centene Management Company LLC is seeking a care management professional to assess, plan and coordinate medical... ...with care teams to ensure smooth transitions and high-quality outcomes. The... ...Behavioral Health, Social Work, or Nursing from an accredited school, plus licensure...Remote job
- ...Health Resources in Fort Worth, TX seeks a Director of Care Transition to lead the daily operation and strategic... ...transition function. The role directs Care Transition Managers (RN & SW) and partners with nurses, physicians, and payors to improve discharge planning...
$140k
...Psychiatric Nurse Practitioner job at Insynch Health PLLC. Texas.... ...effective, and individualized care in a respectful and dignified... ...Nurse Practitioner to join our inpatient psychiatric care hospital. The... ...mandatory. Key Responsibilities: Manage an average caseload of 20-25...Full time- ...Manager Of Inpatient Nursing - Emergency CenterAt our company, our mission starts with our people. Guided by our HEART values of Humility, Excellence... ...operations, and high-quality, family-centered patient care.ResponsibilitiesMaintains clinical competency and ensures patient...Local areaWeekend work
- PAM Health Rehabilitation Hospital of Round Rock is seeking a full-time Case Manager to coordinate interdisciplinary care for patients. The role involves reviewing inpatient admissions and planning discharges, ensuring quality outcomes. The ideal candidate should have...Full time
$50 per hour
...Health Rehabilitation Hospital of Round Rock is seeking a Case Manager for a 13-week internal assignment in Round Rock, TX. The role... ...scheduling. The Case Manager coordinates interdisciplinary inpatient care, reviews admission records, and assesses discharge needs to ensure...Hourly payFlexible hours- ...non-clinical biopsychosocial assessments and interventions for inpatient floors and the outpatient ED. The MSW will assist with discharge... ..., crisis intervention, and referrals, coordinating with care teams to address financial, emotional and psychosocial needs. The...
- Overview The RN Case Manager for High Risk Populations will... ...partners and other care team members to provide... ...working in collaboration with inpatient care teams , ambulatory teams, transitions of care teams and other... ...practices professional nursing as defined by the Texas...Work experience placementLive inWork at officeLocal area
- ...David’s Medical Center in Austin, TX, is hiring a Registered Nurse Case Manager to coordinate patient care across the continuum. You will partner with physicians, nurses, and care teams to ensure safe transitions and effective discharge planning, guiding patients and...
- Texas Health Resources in Dallas is seeking a Care Transition Manager RN to oversee timely transitions of patients to appropriate care levels within the care management team. This full-time, 8:00-4:00, Monday-Friday role emphasizes effective discharge planning and collaboration...Full timeMonday to Friday
- ...to improve your skills. As a Registered Nurse at St. David's Surgical Hospital, you’ll... ...resources you need to deliver safe, high-quality care—so you can focus on what you do best. Job... ...North Austin, the hospital has 45+ large inpatient rooms, 10 operating room suites, and an...Temporary workFlexible hours
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