RN - Case Manager

Transitional Care Management Registered Nurse

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 principles to ensure safe, efficient, and patient-centered care.

Duties and Responsibilities:

• 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, and evaluation of symptoms and clinical concerns.
• Coordinate and schedule timely follow-up appointments with Primary Care Providers and specialists.
• Ensure completion of TCM documentation requirements in the electronic health record system.
• Monitor high-risk patients for complications, worsening symptoms, or readmission risk.
• Escalate clinical concerns to providers promptly using appropriate communication tools.
• Assess social determinants of health.
• 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.

Experience: Minimum 3 years of ambulatory experience preferred License: Client RN License required Certifications: Bachelor's Degree required Must-Have: Epic experience preferred