Case Management Nurse

Company-Provided Equipment We are seeking a fully bilingual English/Spanish RN Case Manager to support high-risk patients through chronic care management, transitions of care, and coordinated care planning. This is a direct-hire, hybrid opportunity based in Tucson. The selected RN will typically work 2–3 days per week onsite at the center, with the remaining days working remotely . Specific onsite days are still being finalized. The ideal candidate will have experience in case management, transitions of care, discharge planning, chronic care management, utilization management, or managed care , along with strong knowledge of post-acute care resources. Key Responsibilities Oversee chronic care management and transitions of care for high-risk patients Serve as a clinical resource to multidisciplinary teams managing complex patients Complete comprehensive assessments addressing physical, mental, and social risk factors Develop and coordinate individualized care plans based on patient needs and identified barriers Perform telephone triage and appropriately address or elevate patient concerns Coordinate patient transitions from acute and post-acute settings to home or other transitional care facilities Collaborate with physicians, nursing staff, ancillary providers, and other members of the care team to remove barriers to appropriate care Coordinate patient care progression across the healthcare continuum Monitor patient progress and intervene as needed to ensure care plans remain patient-centered, high-quality, efficient, and cost-effective Coordinate diagnostic testing, treatment plans, discharge plans, and modifications to the plan of care Ensure patients and families understand discharge instructions, care plans, and follow-up needs Coordinate post-discharge services including home health, hospice, DME, medications, and other medical supplies Schedule patients for PCP or specialist follow-up within 7 days of discharge Reconcile discharge medications and collaborate with PCPs and clinical pharmacists for medication review Review patients for eligibility for home health and other transitional care services Obtain medical records from acute care facilities, including orders, referrals, diagnostic results, and care team documentation Track and monitor hospital readmissions and participate in initiatives designed to reduce avoidable readmissions and hospitalizations Identify at-risk populations using approved screening tools and follow established reporting procedures Coordinate with external case managers and community providers Refer appropriate patients for social work intervention Use clinical, financial, and patient-satisfaction data to identify opportunities for performance improvement Participate in clinical performance improvement initiatives and readmission reduction programs Document assessments, patient calls, and care coordination activities accurately and timely in the EMR Utilize conflict-resolution and problem-solving skills to address barriers to care Maintain knowledge of the Four Elements of the Coleman Model and apply transition-of-care principles Required Qualifications Bachelor’s degree in Nursing (BSN) Fully bilingual in English and Spanish — REQUIRED Candidates must be able to communicate professionally and effectively in both English and Spanish Conversational Spanish alone does not meet the requirement Minimum 2 years of Registered Nurse experience Minimum 2 years of experience in one or more of the following: Case Management Chronic Care Management Transitions of Care Cost/Quality Management Managed Care or related clinical programs Working knowledge of chronic care management, discharge planning, utilization management, case management, and/or managed care reimbursement Knowledge of pre-acute and post-acute care settings and community resources Strong communication, organization, clinical assessment, and care coordination skills Preferred Qualifications Experience with Medicare Advantage Experience in Value-Based Care Managed Care experience Experience working with high-risk or medically complex patient populations Experience with transitions-of-care and readmission reduction programs Experience coordinating home health, hospice, DME, and community-based services Schedule & Work Arrangement Monday–Friday | 8:00 AM–5:00 PM Hybrid Schedule: Typically 2–3 days per week onsite at the Tucson center Remaining workdays are remote Specific required onsite days are currently being finalized #J-18808-Ljbffr