RN - Case Manager

RN - Case Manager

Hours: 8-4pm. Occasional weekends. The position will support a new program that the Quality Department is putting in place.

General Summary: The Transitional Care Management (TCM) Registered Nurse (RN) is responsible for coordinating and managing patient care transitions following discharge from an inpatient facility, emergency department, skilled nursing facility, or other care settings. The TCM RN works collaboratively with providers, practice staff, patients, caregivers, and community resources to reduce readmissions, improve patient outcomes, support quality performance measures, and ensure timely follow-up care in alignment with value-based care initiatives. The TCM RN utilizes evidence-based practices, population health strategies, and High Reliability Organization (HRO) principles to ensure safe, efficient, and patient-centered care.

Duties/Responsibilities:

• Transitional Care Management
• Conduct outreach to discharged patients within required timeframes (typically within 48 business hours of discharge).
• Complete comprehensive post-discharge assessments including:
• Medication reconciliation
• Review of discharge instructions
• Identification of barriers to care
• Evaluation of symptoms and clinical concerns
• Coordinate and schedule timely follow-up appointments with Primary Care Providers (PCP) and specialists.
• Ensure completion of TCM documentation requirements in EPIC.
• Monitor high-risk patients for complications, worsening symptoms, or readmission risk.
• Escalate clinical concerns to providers promptly using appropriate communication tools (SBAR).
• Assessment of social determinants of health
• Care Coordination
• Collaborate with physicians, advanced practice providers, nurses, social workers, care managers, and hospital liaison to ensure continuity of care.
• Facilitate referrals for home care, behavioral health, palliative care, pharmacy support, or community resources as needed.
• Assist patients and caregivers in understanding diagnoses, medications, treatment plans, and self-management strategies.

Job Requirements & Qualifications:

• Previous Charge Experience
• Years of Experience
• Patient Ratio Experience
• Charting System Experience: Required Charting System Name: Epic
• Community Hospital Experience
• Certifications: BLS
• Skills: Age Specific/Population Based Care, Audits, Concurrent Review, Discharge Summary, Familiar with CPT/HCPCS, HIPAA guidelines (Health Insurance Portability and Accountability Act), Lab results blood tests/urine tests, Medicare Guidelines, Nurses notes, Post discharge record review, Post-discharge queries, Retrospective Review, AWV

Submittal Details:

• #Tier2 Travel Compliance
• Prior permanent and travel work history within the Catholic Health Services of Long Island system MUST be listed in the submission profile. If it is discovered to have been left off, it is cause for immediate cancellation of a signed contract.
• Labs: any candidate that accepts an offer needs to be in the lab within 48 hours of acceptance
• Interview availability for the next three business days must be disclosed at submission.
• Catholic only has orientation ONCE A MONTH. It is crucial travelers get started on compliance ASAP
• Must have 2 supervisory clinical references at time of submission or they will be redirected.
• Charge RN references are acceptable
• Prefer at least 1 travel assignment prior to coming to Good Samaritan but not required! Will consider someone with lots of experience.
• Local is defined as within 75 miles of the facility, locals accepted at lower BR for all specialties
• Nursing Assistants: exception, accepted at same rate
• NY State license must be in hand for all nursing positions and Nursys must be provided at submission.
• All Allied certifications must be included at submission.
• If a job is posted for 48 HOURS ONLY. It is not available for 3x12 s. Please ensure to pre-close your traveler prior to submission.
• Modules: Modules are both non-billable and billable
• Non-billable: time spent on modules during 16 hours of NBO
• Billable: time spent on modules after NBO (ex. annually)
• Modules are completed during orientation and annually, and modules vary by specialty
• Modules are self-reported as well as recorded via transcripts and facility reports

Guaranteed Hours: Contract Weeks: 91

Client Details

Address: 245 Old Country Rd

City: Melville

State: NY

Zip Code: 11747