RN - Case Manager

Transitional Care Management Registered Nurse

The Transitional Care Management Registered Nurse is responsible for coordinating and managing patient care transitions following discharge from inpatient facilities, emergency departments, skilled nursing facilities, or other care settings. The TCM RN works collaboratively with providers, practice staff, patients, caregivers, and community resources to reduce readmissions and improve patient outcomes. This role supports quality performance measures and ensures 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.

Key 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 as part of the care coordination process.
• Collaborate with physicians, advanced practice providers, nurses, social workers, and care managers 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.

This position may require occasional weekend work. The ideal candidate will possess strong communication skills and a commitment to improving patient outcomes.

About Cynet Health:

Cynet Health is a Joint Commission-accredited, Minority-Owned healthcare staffing agency headquartered in Sterling, Virginia, proudly serving healthcare facilities across the United States since its founding in 2010. As one of the nation's largest and fastest-growing healthcare staffing firms in the nation, we staff thousands of nursing, allied health, locum tenens, pharmacy, therapy, direct-hire, and non-clinical professionals across hospitals, clinics, long-term care facilities, labs and more. We're one of the most decorated staffing agencies in America-ranked a Top Travel Nursing Company by BluePipes, recognized among the fastest-growing and most diverse staffing firms by Inc. 5000, Staffing Industry, WBJ and USPAACC-and remain deeply committed to excellence, inclusion, and community impact.

We offer competitive benefits, including:

• Medical, dental & vision insurance
• 401(k) with employer match
• Free and unlimited continuing education units (CEUs)
• Disability insurance
• 24/7 dedicated Care Line and clinical liaison support
• Personalized career consultant and "single point of contact" service
• Industry-leading pay rates, loyalty rewards & referral bonuses
• Free tax return assistance for travelers

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