Registered Nurse (RN) Case Manager - Inova Transitional Care (Ambulatory)

Registered Nurse Case Manager

Inova Transitional Care is seeking a Registered Nurse Case Manager to join our ambulatory care team. This role is Monday - Friday, no weekends/no holidays.

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.

Inova Transitional Care (ITC) offers nurses a rewarding opportunity to make a direct and lasting impact on patients during one of the most vulnerable points in their care journeytransitioning from hospital to home. As part of a collaborative, mission-driven team, you will provide patient-centered care to high-risk adult populations, including uninsured and underserved patients, who have been discharged from an Inova hospital or emergency department within the past 30 days and require follow-up for internal medicine conditions.

Nurses in ITC play a critical role in care coordination, patient education, medication management, and closing gaps in care for those without an established primary care provider or timely access to one. You'll have the opportunity to build meaningful relationships with patients while addressing both clinical and social drivers of health through services such as disease education, prescription assistance, case management support, and connections to community resources.

This position is primarily based in our Fairfax clinic, with flexibility to support Alexandria location, offering exposure to diverse patient populations and a highly supportive, team-oriented environment.

With a consistent MondayFriday schedule, no weekends, and Inova-recognized holidays off, this role provides an ideal balance for nurses seeking impactful, relationship-based care while maintaining excellent work-life balance.

• 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)

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.

Minimum Qualifications:

• 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.