Registered Nurse (RN) Case Manager - Inova Transitional Care

Job Description

Inova is consistently ranked a national healthcare leader in safety, quality and patient experience. We are also proud to be consistently recognized as a top employer in both the D.C. metro area and the nation.


The Inova Transitional Care (ITC) bridge gaps in care that patients experience as they transfer across care delivery settings between illness and recovery. The service focuses on transitional medical care and community collaboration to improve health outcomes of patients at the highest risk who lack access to needed resources.


ITC serves adult patients and accepts insurance from all payers and uninsured patients. Patients must have been discharged from Inova Hospital or ED in the last 30 days and have an internal medicine diagnosis(es) needing post-hospitalization follow-up. ITC has a primary focus on caring for high-risk patients without established PCP or who lack prompt access to one.


Clinic services also include disease and medication education, prescription assistance, case management support and community resource connection.


ITC operates clinics in Alexandria, Fairfax, and Leesburg. This position will primarily support the Fairfax clinic with flexibility to provide coverage at all clinic sites, as needed.

• Inova Transitional Fairfax : 2740 Prosperity Ave. STE 200, Fairfax, VA (Primary Work Location)
• Inova Transitional Alexandria: 4700 King Street, STE 100, Alexandria, VA ( occasional need, very rare)

This position is a Monday-Friday (8:30am - 5:00pm) position with no weekends, no on call, and Inova recognized holidays off.

Featured Benefits:

• Committed to Team Member Health: offering medical, dental and vision coverage, and a robust team member wellness program.
• Retirement: Inova matches the first 5% of eligible contributions - starting on your first day.
• Tuition and Student Loan Assistance: offering up to $5,250 per year in education assistance and up to $10,000 for student loans.
• Mental Health Support: offering all Inova team members, their spouses/partners, and their children 25 mental health coaching or therapy sessions, per person, per year, at no cost.
• Work/Life Balance: offering paid time off, paid parental leave, and flexible work schedules

Registered Nurse (RN) Case Manager I Job Responsibilities:

• Collects delay and other data for specific performance and/or outcome indicators. Assists in the collection and reporting of resource and financial indicators including acute and post-acute case mix, LOS, cost per case, excess days, resource utilization, readmission rates, denials and appeals. Collects, analyzes and addresses variances from plans of care and care paths with physicians and/or other members of the healthcare team. Uses concurrent variance data to drive practice changes and positively impact outcomes. Documents key clinical path variances and outcomes which relate to areas of direct responsibility (e.g. discharge planning, chronic disease planning).
• Uses pathway data in collaboration with other disciplines to ensure effective patient management concurrently. Ensures safe care to patients by adhering to policies, procedures and standards within budgetary specifications including time management, supply management, productivity and accuracy of practice. Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency. Supports department-based goals which contribute to the success of the organization.
• Provides discharge planning and continuity of care for assigned patients in the acute and post-acute setting. Initiates and facilitates referrals to clinics, home healthcare, hospice, SNF, acute rehab, LTAC, TCM, medical equipment and supplies as indicated. Collaborates with the interdisciplinary healthcare team, patients and families in the assessment and coordination of discharge planning needs, delivery of post-discharge planning needs, delivery of post-discharge services and transition of patients from hospitals to the discharge setting as well as ongoing care in the community. Documents relevant discharge planning information in medical records according to department standards and/or care management plans.
• Collaborates/communicates with internal and external case managers. Understands pre-acute and post-acute resources. Provides coordination of services and acts as a key Liaison between patients, families and the interdisciplinary healthcare team members. Work closely with members of patients' healthcare teams to manage and coordinate all areas of patients' care. Works holistically to ensure that healthcare plans and discharge plans meet the physical, social and emotional needs of patients.
• Provides educational resources and/or referrals to patients and patients' families to address identified needs such as social or financial. Acts as an advocate for patients to resolve barriers to care progression. Uses utilization management techniques to determine the medical necessity, appropriateness and efficiency of the use of healthcare services, procedures and facilities.

Registered Nurse (RN) Case Manager 1 Minimum Requirements:

• Education: BSN from an accredited school of nursing. If RN has an associate's degree (ADN); must complete BSN within 5 years of start date.
• Experience : Requires a minimum of 1-year Case Management and/or Clinical Care experience.
• Certification: Currently licensed as a Registered Nurse in the State of Virginia or hold a privilege to practice in the State of Virginia under the Enhanced Nurse Licensure Compact (eNLC). Basic Life Support (BLS) for Healthcare Provider certification from the American Heart Association required upon start.

Preferred Qualifications: 1 year of previous case management experience, previous outpatient family medicine practice clinical experience, and bi-lingual (Spanish speaking) is highly preferred.

About Us

We are Inova, Northern Virginia's leading nonprofit healthcare provider. Every day, our 26,000+ team members provide world-class healthcare to the communities we serve. Our people are the reason we're a national leader in healthcare safety, quality and patient experience. And from best-in-class facilities to professional development opportunities, we support them at every step. At Inova, we're constantly striving to be ever better - to shape a more compassionate future for healthcare.


Inova Health System is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to age, color, disability, gender identity or expression, marital status, national or ethnic origin, political affiliation, pregnancy (including childbirth, pregnancy-related conditions and lactation), race, religion, sex, sexual orientation, veteran status, genetic information, or any other characteristics protected by law.