rn transitional care

Wellstar Health System

<div><p>How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.</p><p></p><p><b>
Work Shift</b></p>
Day (United States of America)<p></p><p><b>
WellStar Kennestone Hospital has an opportunity for a Care Coordinator (RN) - Weekend</b></p><p></p><p><b><br>
Part Time - Day Shift - Weekend Only (Friday, Saturday, and Sunday Only)</b></p><p><b>
8:30AM to 5:00PM</b></p><h2 class="jobSectionHeader"><b>
Job Summary:</b></h2><p></p><p><br>
The Care Coordinator RN (CC RN) is responsible for assessing transitional care needs, coordinating care across the continuum, and engaging with patient and family to assure care needs are met. The CC RN plans effectively to meet the patient's needs, manage the length of stay and promote efficient utilization of resources. Overall, the role integrates and coordinates care facilitation, care progression and transitional care planning functions.<br>
Specific functions within this role include:<br>
Psychosocial and functional status assessment, transitional care planning, clinical care progression, facilitate patient/family care conferences, participate in interdisciplinary rounds, and patient/family education<br>
Collaborates effectively with the utilization review nurse, patient's physicians and the interdisciplinary care team to provide a comprehensive assessment of the patient's medical care needs, psychosocial needs, any social determinants of health needs, goals/outcome attainment and continued care needs<br>
Assures that the patient is progressing towards their discharge goal and assists to alleviate barriers<br>
Seeks consultation from appropriate disciplines/departments as required to proactively identify and resolve delays to expedite care and facilitate discharge.<br>
May have other duties assigned</p><p></p><h2 class="jobSectionHeader"><b>
Core Responsibilities and Essential Functions:</b></h2><p></p><div><br>
Assessment<br>
<ul><li>Based on preliminary screening of patients, initiates assessment of patients chronic disease management needs and psychosocial risk factors and availability of resources to assist upon discharge.</li><li>Partners with the PAS, financial counselor and/or UM nurse to assess insurance and coverage requirements for all payers to ensure adherence to those requirements.</li><li>Collaborates with the patient and family, along with the physician(s) and other members of the care team to fully establish and support both the patients care progression and discharge plans..</li><li>Meets with physicians and care team routinely to collaborate on timely and efficient patient management.</li></ul><br>
Disposition Planning<br>
<ul><li>Manages all aspects of discharge planning for assigned patients.</li><li>Implements discharge planning timely and provides resources in an efficient manner.</li><li>Meets with patient/family to assess needs and develop an individualized discharge plan in collaboration with physicians.</li><li>Identifies and documents barriers for timely disposition.</li><li>Ensures/maintains discharge plan consensus with patient/family, physicians, care teams and payers.</li><li>Responds to referrals for patients post-acute needs from physicians and the care team.</li><li>Participates in Interdisciplinary Rounds with the patients care team to confirm estimated date of discharge and make recommendations for best level of care transition at discharge.</li><li>Initiates/facilitates post-acute referrals through departmental processes for timely transition to the next level of care.</li><li>Refer appropriate cases for social work intervention based on departmental protocol.</li><li>Allows for any cultural or religious beliefs in providing service and continuity of care.</li></ul><br>
Care Progression<br>
<ul><li>Collaborates with physicians and care team to facilitate communication regarding patients care progression to ensure timely and efficient delivery of care.</li><li>Proactively identifies delays/obstacles in diagnostic or treatments within the plan of care which can lead to discharge delays.</li><li>Identities and discusses with physician the medical necessity for inpatient testing that may be more appropriate in the outpatient setting.</li><li>Actively works to resolve barriers to discharge and engages/escalates barriers to discharge to the appropriate leader for efficient resolution</li></ul><br>
Documentation<br>
<ul><li>Initial clinical/psychosocial assessment completed and documented in medical record.</li><li>Ensure all records are up-to-date and documentation is clear and concise.</li><li>Ensure timely and accurate documentation in progress notes of interactions with patient/family, physicians, care team, and community partners as it pertains to the patients discharge plan.</li><li>Accounts for and indicates all services arranged/delivered in electronic medical record.</li><li>Track avoidable days and report trends that lead to undesired outcomes.</li></ul><br>
Professional Development and Initiative<br>
<ul><li>Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education.</li><li>Supports department-based goals which contribute to the success of the organization.</li><li>Serves as a preceptor and/or mentor for student interns (if appropriate)</li></ul><br>
Performs other duties as assigned<br>
<br>
Complies with all Wellstar Health System policies, standards of work, and code of conduct.</div><p></p><h2 class="jobSectionHeader"><b>
Required Minimum Education:</b></h2><p></p><p><br>
Associate's Degree in Nursing from an accredited school of nursing with a Georgia RN License Required</p><p></p><h2 class="jobSectionHeader"><b>
Required Minimum License(s) and Certification(s):</b></h2><p><br>
All certifications are required upon hire unless otherwise stated.</p><p></p><ul><li>
Reg Nurse (Single State) or RN - Multi-state Compact</li><li>
Basic Life Support or BLS - Instructor</li></ul><p></p><h2 class="jobSectionHeader"><b>
Additional License(s) and Certification(s):</b></h2><p></p><h2 class="jobSectionHeader"><b>
Required Minimum Experience:</b></h2><p></p><p><br>
Minimum 1 year nursing experience in the acute care setting. Required</p><p></p><h2 class="jobSectionHeader"><b>
Required Minimum Skills:</b></h2><p></p><p><br>
Excellent written and verbal communication skill.<br>
Must possess maturity, self-confidence, objectivity, and positive attitude.<br>
Self-directed with the ability to function well under stress, handle change, and function in a fast-paced environment<br>
Strong assessment, interview, organizational and problem-solving skills.<br>
Knowledge regarding local, state and federal regulations required.<br>
Knowledge of community and state-wide resources and programs.<br>
Ability to work collaboratively with physicians, members of the care team, and the patient/family to assist with progression of care through their transition to the next level of care.</p><p></p><p>
Join us and discover the support to do more meaningful work&mdash;and enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more.</p></div><p></p>

Care Coordinator (RN) - Part-Time/Rotating Weekends

<div><p><b>Summary / Objective:</b><br>
The Care Manager, RN acts in a non-caregiver capacity by facilitating coordination and communication between all members of the health care team in the decision making process to minimize fragmentation of the health care delivery system. As a member of the Care Management Department, this position is responsible for contributing to the standards of quality and service expected by both external and internal stakeholders, including ensuring accurate information flows to interdepartmental teams, proper documentation and adherence to standards related to case management activities.</p>
<div><b>
Essential Functions:</b><br>
<ul><li>Exceed physician, provider and member expectations by providing professional and personalized service at all times.</li><li>Is aware of and continually supports strategic plans that ensure company objectives and goals are obtained.</li><li>Attends collaborative meetings with both internally and externally healthcare team members to support management services for clients served.</li><li>Builds and leverages cross-functional collaborative relationships to facilitate a team-work oriented atmosphere.</li><li>Assess clients for care management services after a referral has been made based on the admission screening and referrals for potential patient issues.</li><li>Develop and manage a coordinated plan of care to meet client and/or family needs</li><li>Assure that clients are placed on appropriate self-management plan and protocols, individualizes client care needs through consultation with the multidisciplinary team.</li><li>Coordinates services to support the appropriate care needs to promote best client outcomes and efficient use of healthcare resources.</li><li>Works with clients and providers to enhance the quality of client management and satisfaction.</li><li>Performs appropriate assessments and develops client-directed care plans within health plan required timeframes and per NCQA standards.</li><li>Assess need to involve medical director or primary care team when appropriate to assist with development of client-directed plan of care.</li><li>Regularly reviews and updates care plans for continuity of care and facilitates plan modifications including barriers to goals.</li><li>Coordinates with Non-Licensed Care Navigators to ensure appropriate follow-up with high risk clients to address identified goals and barriers.</li><li>Documents all interventions and telephone encounters with providers, members and vendors in accordance with established documentation standards.</li><li>Provide comprehensive training for new employees</li><li>Continues own education by keeping his/her knowledge current and conducts independent research of commercial plan guidelines to strengthen general understanding of state and federal resources to support position responsibilities.</li><li>Ensures compliance with departmental and PSW policies and procedures, with special emphasis on compliance with HIPAA privacy and security requirements and all state, federal and plan regulatory mandates.</li><li>Provides Transitional Care Management services post discharge from emergency room, acute inpatient or post-acute inpatient stays.</li><li>Follows Eric Coleman&rsquo;s Pillars of Transitional Care to support reduced risk of adverse events following discharge.</li><li>Provides education on seeking medical attentional early or using urgent care services when appropriate versus an emergency room.</li><li>Follows the standards of care management services as outlined in the guideline manual updated no less than annually.</li><li>Provides telephonic engagements to clients on worklist to meet standards of engagement to include both timing, frequency, and duration of engagements.</li></ul></div>
<div><b>
Knowledge/Skills/Abilities:</b><br>
<ul><li>Set a positive example by displaying a pleasant and approachable demeanor and remaining friendly and courteous at all times.</li><li>Proactive team player, strong follow through, quick decision making abilities and ability to problem solve.</li><li>Interpersonal skills, with the ability to build strong relationships at all levels.</li><li>Strong verbal and written communication skills with customers, supervisors and co-workers.</li><li>Strong organizational, time management and prioritization skills:</li><li>Self-starter. Ability to set priorities and keep to projected schedules.</li><li>Excellent computer proficiency (MS Office &ndash; Word, Excel, Outlook ) including being able to effectively maintain written and computer records in accordance with regulatory agencies.</li><li>Familiarization and experience with Electronic Health Record systems</li></ul></div><div><b>
Required Education and/or Work Experience:</b><br>
<ul><li>Three (3) years of full proficiency clinical experience.</li><li>Verifiable experience or knowledge of a variety of clinical areas of medical treatment as related to general population and pediatric needs.</li><li>Knowledge and experience in providing care management and/or transitional care management services</li></ul></div>
<div><b>
Preferred Education and/or Work Experience:</b><br>
<ul><li>Bachelor&rsquo;s degree from accredited school of nursing.</li><li>Case Manager Certification.</li><li>Experience with commercial health plans.</li></ul></div>
<div><b>
Required Certificates, Licenses and Registrations:</b><br>
<ul><li>Nursing degree (ie: RN)</li><li>Active unrestricted state license in State of Washington.</li></ul></div><br>
<p></p>
<p><i>
*PSW does not typically hire at the top of the pay range *</i></p><p><b>
Benefits:</b></p>
<ul><li>
401(k)</li><li>
401(k) matching</li><li>
Dental insurance</li><li>
Disability insurance</li><li>
Flexible Spending Account (FSA)</li><li>
Health Savings Account (HSA)</li><li>
Health insurance</li><li>
Life insurance</li><li>
Paid time off</li><li>
Tuition reimbursement</li><li>
Vision insurance</li></ul></div>

Care Manager, RN

Children's National Hospital

<div></div><div><div><b>Description</b><div></div><p><br>
The Case Manager Hybrid I/II will provide case management services to patients and their families or caregivers. Assist with assessment, participate in planning and implementation of intervention and ensure follow-up and coordination of services. Engage in outreach activities in the community. Assist with administrative tasks, as needed. All nursing practice is based on the legal scope of practice, national and specialty nursing standards,<br>
Children's National Policies and Procedures, and in accordance with all applicable laws and regulations. The Professional Model of Care requires<br>
registered professional nurses to be responsible and accountable for their own practice. Children's National supports the development of RN<br>
relationships within the community; specifically those relationships associated with the health and well being of the community at large.</p><div><br>
</div></div><div><b>
Qualifications</b><div></div><p><b><br>
Minimum Education</b><br>
Bachelor's Degree (Required)<br>
Master's Degree (Preferred)<br>
<br>
<b>Minimum Work Experience</b><br>
5 years' experience with at least three in an acute setting (Required)<br>
<br>
<b>Required Licenses and Certifications</b><br>
Registered Nurse in District of Columbia (Required)<br>
Current certification in Case Management or Utilization Management (Preferred)<br>
<br>
<b>Functional Accountabilities</b><br>
<b>Professional Practice/Research</b><br>
<br>
Participate in Shared Leadership.</p><ul><li>
Contribute to the MAGNET Journey of Children&rsquo;s National.</li></ul><ul><li>
Ensure nursing practice is based on evidence of best practice.</li></ul><ul><li>
Accountable to participate in the Nursing Division&rsquo;s Performance Improvement process (division or unit level).</li></ul><ul><li>
Participate in community activities.</li></ul><p><b>
Patient Resource Services</b></p><br>
<ul><li>
Communicate denials, high risk, or changes in level of care using accepted processes to limit financial risk to CNMC and patients&rsquo; families.</li></ul><ul><li>
Navigate internal and external systems to accurately identify or secure payers and link patients to needed services.</li></ul><p><b>
Discharge Transitional Plan of Care</b></p><br>
<ul><li>
Define discharge and transitional care criteria with the healthcare team to facilitate efficient care transitions.</li></ul><ul><li>
Conduct an initial assessment of patient and family to identify potential discharge barriers and needs in accordance with departmental and regulatory requirements.</li></ul><ul><li>
Develop and implement a plan of care and make referrals based on a needs assessment and available resources in conjunction with care team members.</li></ul><ul><li>
Transition care to external providers and services to achieve quality outcomes for patient and family .</li></ul><ul><li>
Provide clinical reviews to third party payers using nationally recognized criteria and validate authorization or denial of services and</li></ul><ul><li>
document appropriately in ST AR.</li></ul><p><b>
Documentation</b></p><br>
<ul><li>
Document according to departmental policy.</li></ul><p></p><div><br>
</div></div><div><b>
Primary Location</b><b>:</b> District of Columbia-Washington</div><div><b>
Work Locations</b><b>:</b> Rehab and Specialized Care 1731 Bunker Hill Road NE Washington 20017</div><div><b>
Job</b><b>:</b> Nursing</div><div><b>
Organization</b><b>:</b> Finance</div><div><b>
Position Status</b><b>:</b> R (Regular) - FT - Full-Time</div><div><b>
Shift</b><b>:</b> Day</div><div><b>
Work Schedule</b><b>:</b> M-F 0830-5pm Rotating Weekend on call</div><div><b>
Job Posting</b><b>:</b> Apr 10, 2026, 2:46:33 PM</div><div><b>
Full-Time Salary Range</b><b>:</b> 75545.6 - 125923.2</div></div>

Case Manager Hybrid I/II

URBAN HEALTH PLAN, INC.

<div>
 <strong>
  Job Description
  <br/>
  <br/>
 </strong>
 <strong>
  Position Summary:
  <br/>
  <br/>
 </strong>
 The Bilingual English/Spanish Care Transitions Nurse (RN) is responsible for supporting patients during critical transitions of care, particularly following emergency room visits, hospital discharges, and specialty care episodes. This role ensures timely follow-up, medication reconciliation, care coordination, and patient education to reduce readmissions and prevent gaps in care.
 <br/>
 <br/>
 The Care Transition Nurse works closely with primary care providers, specialists, care management teams, and community partners to ensure continuity of care and improve health outcomes for high-risk and medically complex patients.
 <br/>
 <br/>
 This role supports the organization's population health, quality improvement, and value-based care initiatives by facilitating safe transitions and promoting patient engagement in ongoing care.
 <br/>
 <br/>
 As part of the Virtual Care Center- this role is a fully remote position. Although remote, incumbents are required to engage in in person and Bronx-based service throughout training period, and throughout employment for trainings and meetings when requested. Required schedule included Monday through Friday 9am-6pm shift.
 <br/>
 <br/>
 <strong>
  Minimum Qualifications
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Associates or Bachelors in Nursing is required.
  </li>
  <li>
   NYS Licensed Registered Nurse is required.
  </li>
  <li>
   Minimum of 2-5 years of clinical nursing experience is required in ambulatory care, community health, or related setting.
  </li>
  <li>
   Bilingual Spanish/English is required.
  </li>
  <li>
   Strong care coordination and patient communication skills
  </li>
  <li>
   Knowledge of hospital discharge processes and transitional care management
  </li>
  <li>
   Ability to identify clinical and social determinants of health impacting care
  </li>
  <li>
   Proficiency in electronic health records and care documentation
  </li>
  <li>
   Ability to work collaboratively across multidisciplinary teams
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Key Duties
  <br/>
  <br/>
 </strong>
 <strong>
  Transitional Care Management &amp; Patient Follow-Up
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Conduct outreach to patients following hospital or emergency department discharge
  </li>
  <li>
   Complete Transitional Care Management (TCM) workflows in accordance with CMS guidelines
  </li>
  <li>
   Ensure patients receive timely follow-up appointments with primary care providers or specialists
  </li>
  <li>
   Facilitate specialty care coordination by assisting patients in navigating referrals, scheduling appointments, and ensuring appropriate follow-up with specialty providers.
  </li>
  <li>
   Perform medication reconciliation and assess for medication adherence and safety concerns
  </li>
  <li>
   Identify and address barriers to care, including transportation, social needs, and access issues
  </li>
  <li>
   Perform medication reconciliation and assess for medication adherence and safety concerns
  </li>
  <li>
   Identify and address barriers to care, including transportation, social needs, and access issues
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Care Coordination &amp; Continuity of Care
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Coordinate care between hospital systems, primary care providers, specialists, and community resources.
  </li>
  <li>
   Review discharge summaries and hospital documentation to ensure appropriate follow-up care
  </li>
  <li>
   Facilitate referrals, diagnostic testing, and specialty appointments as needed
  </li>
  <li>
   Support patients in understanding discharge instructions and treatment plans Ensure patients do not fall through gaps in care during transitions
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  High-Risk Patient Management
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Identify high-risk patients based on clinical, social, and utilization risk factors
  </li>
  <li>
   Provide additional monitoring and outreach for patients at risk of readmission
  </li>
  <li>
   Collaborate with care managers, CHWs, behavioral health providers, and social services to address complex patient needs
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Patient Education &amp; Engagement
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Provide patient-centered education regarding diagnosis, medications, warning signs, and follow-up care
  </li>
  <li>
   Promote patient self-management and adherence to treatment plans
  </li>
  <li>
   Encourage ongoing engagement with primary care services
  </li>
  <li>
   Address health literacy and cultural considerations to improve understanding and compliance
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Data Documentation &amp; Reporting
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Document patient encounters and care coordination activities in the EHR
  </li>
  <li>
   Track outreach efforts, successful contacts, and follow-up outcomes
  </li>
  <li>
   Support reporting for Transitional Care Management (TCM) billing and quality measures
  </li>
  <li>
   Contribute to organizational reporting related to readmission reduction and care continuity
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Quality Improvement &amp; Population Health
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Participate in initiatives aimed at reducing avoidable hospitalizations and emergency room utilization
  </li>
  <li>
   Identify patterns or barriers affecting successful transitions of care
  </li>
  <li>
   Collaborate with leadership to improve workflows related to discharge follow-up and care coordination
  </li>
  <li>
   Support quality improvement initiatives related to patient access and care continuity
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Collaboration &amp; Team Integration
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Work closely with providers, care management teams, call center staff, and telehealth teams to coordinate patient care
  </li>
  <li>
   Communicate patient updates and concerns to primary care teams in a timely manner
  </li>
  <li>
   Participate in multidisciplinary meetings focused on high-risk patient management and care planning
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Starting Compensation:
 </strong>
 Minimum $86,560 per year; Maximum $98,560 per year contingent on degree and years of nursing experience.
 <br/>
 <br/>
 <strong>
  As a full time associate at Urban Health Plan, you'll enjoy:
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Fully funded Health Insurance for you/ 73.5% funded Health Insurance for your family
  </li>
  <li>
   Dental, Vision, and Prescription Coverage
  </li>
  <li>
   401(k) Retirement Savings (including 3% annual employer contribution)
  </li>
  <li>
   Comprehensive time off including paid vacation, personal time, sick time, and paid holidays (including your birthday!)
  </li>
  <li>
   Flex Spending Accounts (Health care, Dependent Care, and Commuter Benefits)
  </li>
  <li>
   Entertainment Discount Programs
  </li>
  <li>
   Employee Assistant Program
  </li>
  <li>
   Eligibility to apply for Public Service Loan Forgiveness Program (PSLF)
  </li>
  <li>
   Fitness Discounts and Perks through our medical plan.
  </li>
  <li>
   $50,000 term life Insurance
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  About Urban Health Plan
  <br/>
  <br/>
 </strong>
 At Urban Health Plan (UHP) our mission is to continuously improve the health of communities and the quality of life of the people we serve by providing affordable, comprehensive, quality, primary and specialty health care and by assuring the performance and advancement of innovative best practices. At UHP, our commitment to provide patient-centered, holistic, quality health care, is part of a tradition started by our founder, Dr. Richard Izquierdo, 50 years ago. That tradition continues today by promoting excellence in everything that we do.
 <br/>
 <br/>
 <em>
  UHP is an equal opportunity employer. M/F/D/V. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, sex, sexual orientation, gender identity, gender expression, national origin/ancestry, citizenship status, disability, age, marital or family status, and military or veteran status.
  <br/>
  <br/>
 </em>
 Job Requirements
</div>


Care Transitions Nurse (RN)

University of Southern California

<div><b>Job ID</b> REQ20174951 <b>Category</b> Keck Medicine of USC</div>
<br><div><p>Provides department support for the Continuum of Care Team to facilitate discharge planning and ensure appropriate throughput of patients. Works with Case Managers, Transitional Care Coordinator, and Social Workers to ensure discharge plans are communicated to patients and families during hospitalization and post discharge to ensure continuity and identify clinical barriers. Enables a positive patient experience through the discharge process and connection to resources as needed.</p><p><b>
Essential Duties:</b></p><ul><li>
Partners with members of the Continuum of Care team both case managers and social workers (RN Case Manager, SW Case Manager) in an effort to provide patients and family members a smooth, coordinated patient transition from hospital to home and/or the next level of care.</li><li>
Partners with members of the Care Coordination team to ensure appropriate communication occurs at the point of discharge so that the patients&rsquo; transition is smooth. Provides timely post-acute contact and reinforces post discharge instructions as needed under the direction of the Transitional Care Coordinator.</li><li>
Under the direction and supervision of Transitional Care Coordinator, utilizes multiple referral platforms such as Enso care, e-fax and phone calls etc. to review post-acute referrals. Also reviews discharge instructions and discharge summary to understand patients&rsquo; post-acute plan of care and barriers to follow-up. Provides timely follow-up on all referrals.</li><li>
Under the direction and supervision of the Transitional Care Coordinator, participates in post discharge phone calls to patients. Uses scripts and follows the Cipher Health algorithm for communication with discharged patients.</li><li>
Under the direction and supervision of the Transitional Care Coordinator, communicates frequently and directly with clinic physician staff and other post-acute providers as needed for discharged patients with identified needs.</li><li>
Follows established policies and procedures and workflows regarding post discharge phone calls.</li><li>
Communicates the discharge plan, status of plan to members of the Continuum of Careteam, including allied health care team members. Participates in triad huddles and in the provisioning of assignments of the triad team.</li><li>
Contacts post-acute care facilities as directed by the Continuum of Careteam to assess bed availability, submission of referrals, bed-hold days. Utilizes multiple referral platforms such as faxing, Enso care etc. to facilitate referrals.</li><li>
Coordinates all non-clinical aspects of the discharge planning process as assigned (i.e. durable medical equipment, homeless shelters, non-clinical letters, transportation) reporting any psychosocial needs, barriers or challenges to the appropriate Continuum of Careteam member.</li><li>
Communicates frequently and directly with Continuum of Care team members regarding discharge process needs and priorities. Communicates orders received to the appropriate case manager, works with the Triad team for daily assignments and tasks needing to be completed. Hands off tasks and duties not performed.</li><li>
Participates in departmental meetings, including but not limited to staff meetings, daily huddles, triad huddles, and Continuum of Care team meetings, etc.</li><li>
Utilizes tools (i.e. Medicare.gov website, tablets for patient choice, etc.) as needed to provide patients with skilled nursing facilities and/or information on discharge planning resources within 10 miles or as close to the patient&rsquo;s home as possible.</li><li>
Documents appropriately following departmental standards in the electronic Medical Record.</li><li>
Assists with transfer of patients for lateral and/or acute services.</li><li>
Supports the Continuum of Careteam with arranging transportation using Taxi, Ride Share, ambulance etc.</li><li>
Assists with maintaining and updating current resources (i.e. pamphlets and brochures) for services as needed for post acute care for use by care coordination team.</li><li>
Participates and engages in continuous improvement activities, including huddles and process improvement projects.</li><li>
Follow all departmental standard work and guidelines including the Triad Model of Discharge Planning. Support transitions of care.</li><li>
Develops and maintains positive working relationships with outside post-acute facilities and vendors to promote timely discharge/transfer.</li><li>
Thrives in a fast-paced, multi-faceted team environment, working well with the key stakeholders, meeting tight deadlines, and multitasking a variety of assignments.</li><li>
Strives to support and contribute to the success of the Continuum of Care team&rsquo;s outcome metrics, key performance indicators and /or departmental goals and objectives.</li><li>
Represents the department in a positive and professional manner.</li><li>
Floating between assignments and between Keck and Norris hospitals is required for management of department needs. On-call, weekend coverage and rotation to manage the discharge needs of the patients within the organization is expected.</li><li>
Supports the clinical process for transfer from one level of care to another as medically indicated by the patient&rsquo;s needs. Able to apply clinical knowledge to reference InterQual Discharge Screens and clinical stability for discharge/transition to the next appropriate level of care.</li><li>
Completes clinical authorization process for the discharge medications.</li><li>
Performs other duties as requested/assigned by Director.</li></ul><p><b>
Required Qualifications:</b></p><ul><li>
Req High school or equivalent</li><li>
Req Specialized/technical training Nursing Completion of an accredited vocational nursing program.</li><li>
Req 2 years 2-3 years&rsquo; clinical experience.</li><li>
Req Typing 40-55 WPM. Experience with computer data entry.</li><li>
Req Proficient in Microsoft Office Suite.</li><li>
Req Good organizational skills.</li><li>
Req Strong command of the English language.</li><li>
Req Good customer service skills.</li><li>
Req Ability to multitask and work effectively in a team environment.</li></ul><p><b>
Preferred Qualifications:</b></p><p><b>
Required Licenses/Certifications:
</b></p><ul><li>Req Licensed Vocational Nurse - LVN (CA DCA)</li><li>
Req Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date. (Required within LA City only)</li></ul><br>
The hourly rate range for this position is $28.00 - $47.75. When extending an offer of employment, the University of Southern California considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate&rsquo;s work experience, education/training, key skills, internal peer equity, federal, state, and local laws, contractual stipulations, grant funding, as well as external market and organizational considerations.
<div><b>Job ID</b> REQ20174951 <b>Posted Date</b> 05/08/2026</div></div><p></p>

Discharge Planning Coordinator, LVN - Case Management - Per Diem 8 Hour Days (Non-Exempt) (Union)

CentraCare

<div><p>Join the inpatient Care Management team at St. Cloud Hospital as Registered Nurse Case Manager.
</p><p>As an integral part of the St. Cloud Hospital Case Management System, the Registered Nurse Case Manager works with the interdisciplinary team in facilitating patient care by following the American Case Management Association's Standards of Practice: collaboration, communication, facilitation, coordination, advocacy, and resource management. This Case Manager position will support our Surgical Care and Observation Unit at St. Cloud Hospital. You will be accountable for a designated patient caseload and plan care effectively to meet patient/family transitional needs, monitor length of stay, and promote efficient utilization of resources. Facilitates the collaborative management of patient care across the health care continuum, intervening as necessary to remove barriers to timely and efficient care delivery, and reimbursement.
</p><ul><li>Schedule
<ul><li>Full-time | 80 hours every two weeks | Onsite
</li><li>Day shift | Monday - Friday | 7:30am-4pm
</li><li>Occasional weekend &amp; holiday rotation
</li></ul></li><li>Pay and Benefits
<ul><li>Pay rate minimum: $42.37 (BSN); $43.43 (MSN), pay determined by experience
</li><li>Earn extra pay for working weekend shifts
</li><li>$3,500 hiring bonus and $5,000 relocation bonus for eligible candidates!
</li><li>Full time benefits : medical, dental, PTO, retirement, employee discounts and more!
</li><li>Tuition reimbursement and college grant programs available
</li></ul></li><li>Qualifications
<ul><li>Graduate from a nursing program
</li><li>BSN or higher degree in nursing required.
</li><li>2 years or more of clinical experience as an RN required.
</li><li>Registered Nurse in MN required.
</li><li>Current American Case Management Association (ACMA Certification - RN) or obtained within 5 years required.
</li></ul></li></ul><p>Hiring bonus requirements: To be eligible for the hiring bonus you must be an external candidate who is hired into an eligible full-time or part time benefited position. Previous CentraCare/Carris employees qualify if they have not worked for CentraCare for at least 9 months at the date of hire.
</p><p>Relocation assistance requirements: Must accept a position that offers benefits and may not have worked for CentraCare in the last 9 months. Must currently reside more than 50 miles away from St. Cloud Hospital and relocate to within 30 miles of it.
</p><p>**CentraCare pay promotions to include but not limited to, Accelerated Rates and Bonuses may be discontinued at any time due to business needs**
</p><p>CentraCare Health has made a commitment to diversity in its workforce and all individuals, including, but not limited to, individuals with disabilities, are encouraged to apply. CentraCare Health is an EEO/AA employer.</p></div><p></p>

Case Manager Registered Nurse

Cooper University Healthcare

<div><b>About us</b><br>
<br>
<br>
<div>At<b> </b><b>Cooper University Health Care</b>, our commitment to providing extraordinary health care begins with our team. Our extraordinary professionals are continuously discovering clinical innovations and enhanced access to the most up-to-date facilities, equipment, technologies and research protocols. We have a commitment to our employees to provide competitive rates and compensation programs. Cooper offers full and part-time employees a comprehensive benefits program, including health, dental, vision, life, disability, and retirement. We also provide attractive working conditions and opportunities for career growth through professional development.</div><div></div><div><br>
Discover why Cooper University Health Care is the employer of choice in South Jersey.</div><b><br>
Short Description</b><div><br>
The Critical Care Tech II, under the direction of a Registered Nurse (RN), assists with patients&rsquo; activities of daily living and supports the overall plan of care. This role involves direct communication with and support for the healthcare team, patients, and their families or significant others. The position requires maintaining high standards of professional ethics and contributing to the delivery of quality patient care within the organization.</div><ul><li>
Support patients&rsquo; activities of daily living (bathing, dressing, feeding, hygiene, mobility, transport) and follow standard precautions</li><li>
Perform technical duties as directed by RN (phlebotomy, vital signs, point of care testing, EKGs, Foley catheter care) and document appropriately.</li><li>
Identify and communicate changes in patient status to RN and respond appropriately, maintaining safe patient practices</li><li>
Reinforce education for patients and families regarding care needs and safety</li><li>
Participate in patient satisfaction initiatives, performance improvement activities, and assist in orienting new hires.</li><li>
Complete annual hospital and unit-specific competencies by the required due date.</li><li>
Consistently adhere to safety protocols and quality standards to ensure a safe environment and high-quality patient care</li><li>
Effective communication skills for interacting with patients, visitors, and coworkers.</li><li>
Capacity to identify and communicate changes in patient status.</li></ul><br>
<b>
Overview<br>
</b><br>
<br>
<p>Pavilion-6, an Intermediate surgical and medical surgical unit with 30 single rooms, is deeply committed to providing exceptional patient care. Our surgical services include surgical oncology, urology, bariatrics, and thoracic and colorectal surgery. Our leadership structure, comprised of a clinical director, an assistant clinical director, clinical nurse managers, and a clinical educator, is dedicated to supporting our staff and patient safety.</p><p>
Pavilion-6 is supported by our unit secretaries, critical care technicians and registered nurses seven days a week. We work towards having all of our nurses&rsquo; cross-trained in surgical intermediate within the first year at Cooper. Pavilion-6 fosters a close relationship with our providers, as our APN&rsquo;s and Surgical Residents are easily accessible for support, questions, and directions with patient care. They have offices right here on the unit, along with our leadership team and our transitional care team.</p><b><br>
Experience Required</b><br>
<ul><li>
0-2 years&rsquo; experience required.</li></ul><br>
<b>
Education Requirements</b><br>
<ul><li>
High School/GED required.</li><li>
Successful completion of Patient Care Technician training and have an active Patient Care Technician Certification required.</li></ul><br>
<b>
License/Certification Requirements</b><br>
<ul><li>
AHA Basic Life Support certification required</li><li>
Successful completion of one of these certifications; CPT, CPCT-A, ACMA</li></ul><br>
<b>
Special Requirements</b><p><br>
PT days, hours</p><p>
7a-7:30p with weekend/holidays rotation</p></div>
<br>
Part Time
<br>
Day

CERTIFIED CRITICAL CARE TECH-PAVILION 6

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