transitional care manager

<div>Summary / Objective: 
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.
<div>
Essential Functions: 
<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>
Knowledge/Skills/Abilities: 
<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>
Required Education and/or Work Experience: 
<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>
Preferred Education and/or Work Experience: 
<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>
Required Certificates, Licenses and Registrations: 
<ul><li>Nursing degree (ie: RN)</li><li>Active unrestricted state license in State of Washington.</li></ul></div> 


*PSW does not typically hire at the top of the pay range *
Benefits:
<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

Aegis Medical Group

JOB SUMMARY:The TCM Coordinator plays a vital role in ensuring safe, timely, and coordinated transitions of care from hospital to home or other care settings. This position is responsible for managing and coordinating all post-discharge activities, including patient follow-up, medication reconciliation and communication between patients and care teams.JOB DUTIES:JOB REQUIREMENTSKey Responsibilities:<ul><li>Review daily cases for admissions and discharges for inpatient stays and ER visits</li><li>Conduct post-discharge follow-up calls within 24&ndash;48 hours to review medications and report and concerns to clinic nurse</li><li>Schedule TCM appointment with PCP within 5 days of discharge</li><li>Identify and escalate any clinical concerns or red flags to the appropriate care provider or clinic nurse</li><li>Collaborate with care teams for continuity of care</li><li>Access hospital portals to track admissions and retrieve discharge summaries and diagnostic results</li><li>Document all patient interactions and follow-ups in the electronic health record (EHR) in a timely and accurate manner</li><li>Assist with quality improvement initiatives related to discharge processes and readmission reduction</li><li>Maintain up-to-date knowledge of discharge protocols, transitional care workflows, and healthcare resources</li></ul>Education and/or ExperienceQualifications:Required:<ul><li>Medical Assistant or related experience</li><li>Understanding of medical terminology</li><li>At least 3 years of experience in a clinical setting</li><li>Familiarity with EHR systems (e.g., eCW, Epic, Cerner)</li></ul>Preferred:<ul><li>Experience with care coordination and chart reviews</li><li>Strong communication and patient education skills</li></ul>Skills &amp; Abilities:<ul><li>Excellent interpersonal and organizational skills</li><li>Ability to multitask and manage time effectively in a fast-paced environment</li><li>Ability to navigate through multiple electronic systems simultaneously</li><li>Empathy, patience, and a patient-centered approach</li><li>Strong attention to detail and follow-through</li><li>Ability to work independently and as part of a multidisciplinary team</li></ul>WORK ENVIRONMENTAll work is performed within a standard health care/primary care clinical setting.DISCLAIMERThe duties and responsibilities, qualifications, physical conditions, and other statements contained herein represent the current general nature of the job described, and are subject to change at any time, with or without notice. This job description does not limit in any way the assignments that may be given to an employee in the job, and employees are expected to perform all duties assigned by their supervisor willingly and without reservation.Job Type: Full-timePay: $16.50 - $19.50 per hourBenefits:<ul><li>401(k)</li><li>401(k) matching</li><li>Dental insurance</li><li>Employee assistance program</li><li>Health insurance</li><li>Health savings account</li><li>Life insurance</li><li>Paid time off</li><li>Parental leave</li><li>Professional development assistance</li><li>Referral program</li><li>Tuition reimbursement</li><li>Vision insurance</li></ul>Application Question(s):<ul><li>How many years of Medical Assistant experience do you have?</li><li>Do you have a valid Certified Medical Assistant Certificate? </li><li>Do you have experience working with EHR systems (eCW, Epic, Athena)?</li><li>Have you ever worked for Aegis Medical Group and/or Lakeview Healthcare System?</li></ul>Experience:<ul><li>clinical setting: 3 years (Required)</li></ul>Language:<ul><li>Spanish (Preferred)</li></ul>Work Location: In person

TCM Coordinator

Avail Health

<div>About Avail Health
Avail Health is a Nurse Practitioner&ndash;founded organization dedicated to removing barriers to care, access, and meaningful clinical work for Medicare-age individuals. We combine thoughtful technology, strong operational infrastructure, and deep respect for the patient&ndash;provider relationship to enable nurse-led virtual and mobile care models. As a fast-growing organization, we are building durable clinical infrastructure to support innovative care programs across multiple states, with a focus on improving outcomes for complex and underserved senior populations.
Role Summary
The Senior Manager, RN &ndash; Care Transitions is a frontline leadership role responsible for supporting the day-to-day execution of Avail Health&rsquo;s Care Transitions Program in partnership with hospital teams and community stakeholders.
This role serves as the primary on-site presence for Avail Health within the hospital environment, helping to identify eligible patients, coordinate transitions of care, and support patient engagement following hospital discharge.
The Senior Manager will act as the local team leader for the care transitions team, supporting coordination of team activities and limited people management responsibilities while working closely with the senior leadership team, who maintain accountability for overall program strategy and clinical oversight.
A central component of this role is building strong partnerships with hospital leadership and frontline teams, serving as the face of Avail Health for both hospital stakeholders and patients entering the program.
The ideal candidate brings strong clinical assessment and critical thinking skills, particularly in evaluating patient risk and determining appropriate program engagement for complex Medicare-aged populations transitioning from hospital to home.
Reports to: VP of Care Delivery 
Location: This position is primarily in-person and must be located within the geographic region of Rockville, Maryland, or within a reasonable commuting distance.
Work Environment: The role requires primarily in-person presence Monday through Friday within the hospital environment, participating in daily care coordination activities with hospital teams, including interdisciplinary huddles and care planning discussions.
In addition to hospital-based work, the role will include mobile clinical engagement with patients following discharge, including in-home visits as well as telephonic or virtual interactions when clinically appropriate. At program launch, mobile visit volume is expected to be limited, with responsibility increasing as the program scales. The role will also provide coverage and support for team RNs, and participation in mobile visits is an ongoing expectation of the position.
Limited remote work may occur for administrative, coordination, or leadership activities when not required on-site. Remote work requires a reliable high-speed internet connection and a dedicated, HIPAA-compliant workspace to ensure the security and confidentiality of patient information and organizational communications.
This role may also include occasional participation in an on-call rotation to support clinical questions from care team members outside of standard business hours. The structure and frequency of this coverage will evolve as the program scales.
Key Responsibilities
Hospital Partnership &amp; Customer Success<ul><li>
Serve as the primary on-site representative of Avail Health within the hospital environment, building strong relationships with hospital leadership, care management teams, and frontline clinical staff.</li><li>
Participate in hospital coordination activities including daily huddles, rounds, and care planning discussions to identify patients eligible for the Care Transitions Program.</li><li>
Support effective collaboration and warm handoffs between hospital teams and Avail Health to ensure smooth transitions from hospital to home.</li><li>
Represent Avail Health professionally and help ensure a positive partnership experience for hospital stakeholders.</li></ul>
Patient Identification &amp; Program Enrollment<ul><li>
Review hospital discharge lists and clinical documentation to identify patients eligible for the Care Transitions Program.</li><li>
Conduct patient outreach, assessments, and enrollment discussions with eligible patients and caregivers.</li><li>
Apply strong clinical judgment to assess patient complexity and risk factors, supporting appropriate prioritization and engagement within the program.</li><li>
Coordinate with hospital teams to facilitate timely program enrollment and continuity of care following discharge.</li></ul>
Team Leadership &amp; Program Execution<ul><li>
Serve as the local team leader for the Care Transitions care team, helping coordinate day-to-day team activities and patient workflows.</li><li>
Provide limited people management for clinical and community-based staff during the early stages of program launch.</li><li>
Collaborate closely with the senior leadership team to support team operations, workflow management, and operational coordination.</li><li>
Execute program workflows and care coordination processes established by leadership while providing frontline insights that help inform ongoing program improvement.</li><li>
As the program scales, additional operational leadership roles will be introduced to support team growth and operational infrastructure.</li></ul>
Care Coordination &amp; Cross-Program Navigation<ul><li>
Support coordination of care for patients transitioning from hospital to home across both medical and behavioral health populations.</li><li>
Facilitate referrals into appropriate hospital programs, community resources, and Avail Health care programs when clinically appropriate.</li><li>
Help ensure patients and caregivers understand and successfully navigate post-discharge care plans.</li></ul>
Technology &amp; Program Infrastructure<ul><li>
Utilize Avail Health&rsquo;s technology platforms and tools to support patient identification, care coordination, and program tracking.</li><li>
Partner with hospital teams to support adoption of program tools, including customized dashboards and reporting used to track program engagement and outcomes.</li><li>
Serve as a knowledgeable frontline resource for hospital stakeholders using Avail technology platforms, helping address day-to-day questions and ensuring effective use of program tools.</li><li>
Collaborate with Avail&rsquo;s technology and operations teams to provide feedback that helps refine tools and workflows as the program evolves.</li></ul>
Qualifications
Required:<ul><li>
Active, unrestricted Maryland Registered Nurse (RN) license in good standing.</li><li>
Current Basic Life Support (BLS) certification.</li><li>
Minimum 5+ years of clinical RN experience with some prior mobile nursing experience, providing care to patients where they reside.</li><li>
Experience supporting post-hospital transitions of care, discharge planning, or complex care coordination.</li><li>
Minimum 2+ years of experience supervising or coordinating clinical staff or care teams.</li><li>
Strong clinical assessment and critical thinking skills managing complex patient populations.</li><li>
Excellent interpersonal and communication skills with the ability to build strong relationships with hospital teams and patients.</li><li>
Ability to operate effectively in a new program environment with evolving workflows and processes.</li></ul>
Preferred:<ul><li>
Experience in hospital care management or discharge planning environments, transitions of care (TOC), transitional care management (TCM) or hospital readmission reduction programs.</li><li>
Emergency Department (ED) triage experience is highly preferred.</li><li>
Experience delivering home-based care through home health, hospice, or mobile care programs.</li><li>
Experience working with Medicare-aged populations with complex medical or behavioral health needs.</li><li>
Experience supporting clinical workflows, program implementation, or new care model launches.</li></ul>
What Success Looks Like
Success in this role will include the ability to:<ul><li>
Build strong, trusted relationships with hospital teams and serve as an effective on-site program partner.</li><li>
Identify and enroll appropriate patients through strong clinical assessment and patient engagement.</li><li>
Coordinate the local care transitions team effectively during program launch.</li><li>
Ensure consistent execution of program workflows and care coordination processes.</li><li>
Contribute to improved patient transitions from hospital to home and reductions in avoidable hospital utilization.</li><li>
Provide actionable frontline insights that help inform ongoing program refinement.</li><li>
A positive, collaborative team culture aligned with Avail Health&rsquo;s values.</li></ul>
Compensation &amp; Benefits<ul><li>
Total Salary: $110,000 &ndash; $126,500 annually, inclusive of base salary plus a 10% geographic market adjustment for the Montgomery County metropolitan region, commensurate with experience.</li><li>
Performance Bonus: quarterly bonus up to 2.5% of base salary (up to 10% annually) based on individual and program performance metrics.</li><li>
Annual Compensation Review: up to 5% of base salary, based on performance and organizational factors.</li><li>
Benefits Package: medical, dental, and vision insurance, subject to plan terms and eligibility requirements.</li><li>
Paid Time Off: 3 weeks annually, accrued per pay period.</li><li>
Holidays: 8 paid company holidays plus 1 floating holiday per calendar year.</li><li>
Retirement: 401(k) retirement plan with a 2% employer match, subject to plan terms and eligibility requirements.</li></ul>
Pay: $110,000.00 - $126,500.00 per year
Benefits:<ul><li>
401(k) matching</li><li>
Dental insurance</li><li>
Health insurance</li><li>
Life insurance</li><li>
Paid time off</li><li>
Vision insurance</li></ul>
Application Question(s):<ul><li>
Please describe your experience supporting patients transitioning from hospital to home. Include examples of how you have assessed patient risk, prioritized follow-up, or made triage decisions (e.g., ED, discharge planning, or care management settings).</li><li>
Describe your experience leading or coordinating a clinical team. How have you supported team operations, guided workflows, or ensured effective patient care delivery in a fast-paced or evolving environment?</li><li>
This role requires working as an external partner with hospital leadership and frontline teams to support discharge planning, while also engaging directly with patients to assess eligibility and enroll them into the program. Please describe your experience collaborating with hospital teams in this type of partnership setting, and how you have built trust while coordinating care and engaging patients or families in care decisions or program participation.</li></ul>
Experience:<ul><li>
RN: 5 years (Required)</li></ul>
License/Certification:<ul><li>
RN License (Required)</li></ul>
Work Location: On the road
ADvov9Ww1i</div>

Senior Manager, RN - Care Transitions

Home for Families

Home for Families is proud to be recognized as one of the Columbus Foundation&rsquo;s Top Nonprofits to Watch in 2026 and maintains the highest ratings for organizational transparency with Guidestar, Charity Navigator, and the Better Business Bureau. **Position Overview:** We do offer flexible schedules with a minimum of 2 days per week on site****This position reports to the Director of Transitional Age Youth (TAY) Services and is responsible for providing housing case management services for Transition Age Youth (age 18-24) experiencing homelessness, including intake, assessment, housing search and placement, home visits, and linkage to community resources.Key Responsibilities:<ul><li>Conducts intakes and assessments, then building a goal plan that is directed by the clients&rsquo; expressed needs and wants</li><li>Identifies landlords and provides advocacy for clients in regards to housing</li><li>Provides intensive case management for approximately 10-15 clients at any one time, focusing on housing stability, decreasing barriers and increasing self-sufficiency</li><li>Utilizes a strengths-based approach and focus on building appropriate relationships with clients in order to help them be successful in reaching their goals</li><li>Provides advocacy and mediation with landlords, when necessary</li><li>Works with youth-focused partner agencies and HFF&rsquo;s TAY team to provide comprehensive services to clients</li><li>Learns about and stays current in regards to community resources that can assist clients</li><li>Maintains files and stays current with all required paperwork</li></ul>Qualifications:<ul><li>Bachelor&rsquo;s degree in social work or related field preferred</li><li>Extensive knowledge of community agencies and resources in and around Columbus</li><li>Case Management experience working with homeless populations required</li><li>Experience working with clients age 18-24 preferred</li><li>Working knowledge of Trauma-Informed Care and Cultural Competency</li><li>Ability to both take direction and work independently</li><li>Congruence with agency mission and values required</li><li>2+ years&rsquo; experience working with families with significant barriers required</li><li>Demonstrated skills, knowledge and experience in the following areas required:</li></ul>o Ability to manage a caseload while also balancing administrative dutieso Microsoft Word, Excel and Power Point&middot; Knowledge of federal, state, and local public policies, regulations, and guidelines relative to homelessness, affordable housing and education.<ul><li>Valid driver&rsquo;s license, proof of automobile insurance, ability to drive an agency vehicle, ability to successfully pass a pre-employment drug screen, and ability to pass a criminal background check required</li><li>Physical ability to lift and carry file boxes and supplies up to 25 lbs. occasionally required</li></ul>Job Type: Full-timePay: $22.00 - $25.00 per hourBenefits:<ul><li>Dental insurance</li><li>Flexible schedule</li><li>Health insurance</li><li>Paid time off</li><li>Vision insurance</li></ul>Experience:<ul><li>Case management: 1 year (Preferred)</li></ul>Work Location: In person

Transitional Age Youth Housing-Case Manager

Heritage Provider Network

<div>Position Summary:

The Inpatient Transfer Team Case Manager is responsible for the assessment, treatment planning, intervention, monitoring, evaluation and documentation on identified patients during an acute care episode. Assesses and develops a care plan in collaboration with the admitting, attending and consultant physicians, and other healthcare practitioners. The goal of the Inpatient Transfer Case Manager is to effectively identify which Medi-Cal members need to be transferred from a non-capitated hospital and work in collaboration with the hospitalist(s), Medical Director(s), hospital staff to facilitate timely transfer into the campus capitated hospital. The Inpatient Transfer Case Manager is to manage the patients during their hospitalization to assure the right level of care is provided for the patient's current severity of illness, utilizing the appropriate tests and diagnostics, in the appropriate facilities in order to provide the highest level of care, in the most efficient manner, while utilizing only the resources necessary for that episode of care. The Inpatient Transfer Case Manager is also responsible for the safe discharge of patients with the necessary resources to insure that care is provided without interruption along the continuum of care, that is, whether in a skilled nursing facility, assisted living facility or in the home setting. Such discharge will be planned and coordinated in collaboration with the Vital Care Case Manager for patients enrolled in the Vital Care program. The Inpatient Transfer Case Manager will document the discharge plan, together with the current medication list, and scheduled follow-up appointments in the authorization notes and will communicate the same to the Vital Care Case Manager, the patient, and family members concerned. A follow-up post-discharge call will be made by the Inpatient Transfer Case Manager or the department's designee within 24 hours of discharge to determine any problems, issues, or risks encountered in the transition.

Essential Duties and Responsibilities include the following:

<ul><li>Anticipates our customer needs: Understands the wants and needs of customers, listens for cues and identifies how to respond and at the appropriate level of intervention needed.
</li><li>Surveys the customer's environment and takes appropriate action.</li>
<li>Refrains from discussing personal business in front of the customer or speaking a foreign language different from the customer's language.</li>
<li>Greets patients, family members, visitors, and physicians in a positive manner by introducing self, speaking clearly and with confidence.</li>
<li>Returns phone calls to customers and follows up with requests.</li>
<li>Keeps patient/family member or other customer informed and requests if further assistance is needed.</li>
<li>Assists others and supports the team.</li>
<li>Demonstrates the ability to follow through with requests, sharing of critical information, and getting back to individuals in a timely manner.</li>
<li>Demonstrates honesty and integrity in everyday activities.</li>
<li>Recognizes when an error is made and reports them appropriately.</li>
<li>Protects privacy for both patients and employees; ensures information sensitive papers, charts, and reports are not in view of the public.</li>
<li>Recognizes when an error has been made and immediately reports to appropriate manager.</li>
<li>Participates in &ldquo;service recovery&rdquo; through follow-up with the injured party, gathering information, and demonstrates empathy.</li>
<li>Treats patients and their families with respect and dignity. Identifies and addresses psychosocial, cultural, ethnic, and religious/spiritual needs of patients and their families. Functions as liaison between administration, patients, physicians, and other healthcare providers.</li>
<li>Interacts professionally with patient/family/physicians and involves patient/family/physicians in the formation of the plan of care.</li>
<li>Communicates appropriately and clearly to management, co-workers, and physicians.</li>
<li>Identifies and addresses psychosocial needs of the patients and family and facilitates consultations with a Social Worker, as necessary.</li>
<li>Formulates a teaching plan based upon identified learning needs and evaluates effectiveness of learning; family is included in teaching as appropriate.</li>
<li>Communicates using age appropriate language.</li>
<li>Understands and applies principles of adult learning methods as they relate to health care educational needs.</li>
<li>Receives and reviews physician's orders; documents completion. Follows through to ensure orders are carried out.</li>
<li>Consults other departments as appropriate to provide for an interdisciplinary approach to the patient's needs.</li>
<li>Formulates an outcome-based plan or care, based on assessed patient needs, implements and evaluates plan as evidenced by documentation.</li>
<li>Maintains quality monitors as assigned by Supervisor.</li>
<li>Participates in orientation, instruction/training of new personnel.</li>
<li>Pursues additional education (in-services, seminars, self-study, and formal education programs) to advance nursing skills and knowledge.</li>
<li>Documents patient assessment and reassessment, patient care plans and other pertinent information completely, in the patient's medical record according to nursing standards and policies.</li>
<li>Assures complete and proper charging of supplies.</li>
<li>Participates in the efficient, effective, and responsible use of resources such as supplies and equipment.</li>
<li>Completes daily documentation, required letters, and referrals in a timely manner.</li>
<li>All other duties as directed by management.</li>
</ul>
The pay range for this position at commencement of employment is expected to be between LVN $37.50 - $40 per hour or for RN $45 - $50; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, licensure, skills, and experience.
Details of participation in these benefit plans will be provided if an employee receives an offer of employment.

If hired, employee will be in an &ldquo;at-will position&rdquo; and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.

As one of the fastest growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare &amp; Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our success.

Employer will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of the LA City Fair Chance Initiative for Hiring Ordinance.
Requirements:
Education and/or Experience:
<ul><li>Graduate from an accredited RN Nursing Program.</li></ul>
<ul><li>Current California Licenses</li></ul>
<ul><li>Knowledge of Healthcare and Managed Care preferred.</li></ul>
<ul><li>Typing 40 words per minutes with accuracy.</li></ul>
<ul><li>Knowledge of computers, faxes, printers and all other equipment.</li></ul>
<ul><li>Knowledgeable in MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point).</li></ul>
<ul><li>Ability to deal with responsibility with confidential matters.</li></ul>
 
Compensation: $37.50/hour - $40/hour LVNs ; $45-$50/hour RNs</div>

Transfer Case Manager, RN Part Time

Children's National Hospital

<div></div><div><div>Description<div></div> 
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, 
Children's National Policies and Procedures, and in accordance with all applicable laws and regulations. The Professional Model of Care requires 
registered professional nurses to be responsible and accountable for their own practice. Children's National supports the development of RN 
relationships within the community; specifically those relationships associated with the health and well being of the community at large.<div> 
</div></div><div>
Qualifications<div></div> 
Minimum Education 
Bachelor's Degree (Required) 
Master's Degree (Preferred) 
 
Minimum Work Experience 
5 years' experience with at least three in an acute setting (Required) 
 
Required Licenses and Certifications 
Registered Nurse in District of Columbia (Required) 
Current certification in Case Management or Utilization Management (Preferred) 
 
Functional Accountabilities 
Professional Practice/Research 
 
Participate in Shared Leadership.<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>
Patient Resource Services 
<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>
Discharge Transitional Plan of Care 
<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>
Documentation 
<ul><li>
Document according to departmental policy.</li></ul><div> 
</div></div><div>
Primary Location: District of Columbia-Washington</div><div>
Work Locations: Rehab and Specialized Care 1731 Bunker Hill Road NE Washington 20017</div><div>
Job: Nursing</div><div>
Organization: Finance</div><div>
Position Status: R (Regular) - FT - Full-Time</div><div>
Shift: Day</div><div>
Work Schedule: M-F 0830-5pm Rotating Weekend on call</div><div>
Job Posting: Apr 10, 2026, 2:46:33 PM</div><div>
Full-Time Salary Range: 75545.6 - 125923.2</div></div>

Case Manager Hybrid I/II

Your Health

<div>
 
 We are seeking a Licensed Nurse to fill our Track Case Manager LPN/ RN position to assist with all clinical scheduling needs for our Rock Hill patients.
 
 The Track Case Manager is responsible for overseeing and managing patient scheduling, care coordination, and follow-up for high-risk, acute, and transitional care patients within their assigned region. This role requires close monitoring of scheduling buckets, addressing urgent patient needs, and ensuring seamless communication between the care team, patients, and referral sources. The Track Case Manager will work a seven-day track schedule, providing comprehensive case management coverage and ensuring that patient care is aligned with Your Health&rsquo;s care model.
 
 
 
 This position will remote working with the Rock Hill Office daily.
 
 This is a full-time, salary-based 12-hr position Monday-Sunday (7:00AM-7:00PM) 7days on, 7 days off schedule.
 
 
 
 About
 
 
 
 We are a leading physician group serving South Carolina and Georgia, dedicated to delivering quality healthcare directly to patients in care facilities, homes, clinics, and virtual visits. Our services include comprehensive primary care, specialty services, and pharmacy support, tailored to meet diverse patient needs. Committed to excellence and innovation, our team collaborates closely with facilities and families to ensure accessible, coordinated, and compassionate care.
 
 
 
 Why Choose a Career at Your Health?
 
 
 
 Providing high quality care for our patients is the center of what we do, and we provide the same care for our employees. Here are some of the benefits that are available to our employees.
 
 
 <ul>
 <li>
 Competitive Compensation Package with Bonus Opportunities
 </li>
 <li>
 Employer Matched 401K
 </li>
 <li>
 Free Visit &amp; Prescriptive Services with HDHP Insurance Plan
 </li>
 <li>
 Employer Matched HSA
 </li>
 <li>
 Generous PTO Package
 </li>
 <li>
 Career Development &amp; Growth Opportunities
 
 
 </li>
 </ul>
 
 What Are We Looking For?
 
 
 
 Your Health is currently looking for a Track Case Manager to join our growing Primary Care family. A successful Track Case Manager will be able to perform these essential duties and responsibilities.
 
 
 Reasonable accommodations may be made, in accordance with applicable law, to enable individuals
 
 
 
 With Disabilities To Perform The Essential Functions
 
 
 
 The following is a list of essential functions, which may be subject to change at any time and without
 
 
 notice. Management may assign new duties, reassign existing duties, and/or eliminate function(s)
 
 
 
 Areas Of Responsibility
 
 
 
 <ul>
 <li>
 New Patient Triage: Evaluate and prioritize new patient referrals to determine appropriate service needs based on medical history, presenting conditions, and provide availability.
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 Work closely with the care team to ensure patients are placed in the correct care pathway.
 </li>
 <li>
 High-Risk Patient Management: Review and manage care for high-risk patients, including scheduling appointments and follow-ups.
 </li>
 <li>
 Scheduling Buckets: Closely monitor and manage appropriate scheduling buckets, including region and transitional care management scheduling buckets
 </li>
 <li>
 Acute/Urgent Case Management: Address all new patient cases, acute/urgent requests, TCM patient cases, and other high-risk scenarios promptly.
 </li>
 <li>
 Track Partner Collaboration: Monitor and address tasks in the track partners bucket, ensuring no delays in patient care.
 </li>
 <li>
 New Patient Intake &amp; Scheduling: Conduct initial screenings for new patients to assess care needs, verify eligibility, and coordinate timely scheduling.
 </li>
 <li>
 Ensure appropriate documentation and communication with providers regarding patient history, concerns, and special care requirements.
 </li>
 <li>
 Evaluate the patient to determine the most appropriate place of service for care, such as in-home services or clinic-based care, based on medical necessity, provider recommendations, and patient preference.
 </li>
 <li>
 Appointment Scheduling: Schedule patients promptly according to the Care Model, including TCM visits, acute cases, and follow-ups per frequency guidelines.
 </li>
 <li>
 Patient and Family Communication: Maintain strong communication, follow-up, and follow through with patients, families, and referral sources.
 </li>
 <li>
 Phone and Voicemail Management: Monitor incoming new patient calls during shift and promptly address voicemails by returning calls and ensuring the patient needs are promptly addressed.
 </li>
 <li>
 Assign follow-up calls to appropriate regional case management team members and monitor for timely completion.
 </li>
 <li>
 Insurance Verification: Prompt insurance verification when scheduling patients to ensure coverage and eligibility.
 </li>
 <li>
 Team Coordination: Collaborate with care teams, review care group chats, and attend required monthly meetings to ensure seamless operations.
 
 
 </li>
 </ul>
 
 Qualifications
 
 
 
 <ul>
 <li>
 A licensed nurse is required. Nursing license must be in good standing.
 </li>
 <li>
 A minimum of two (2) years of clinical experience is required.
 </li>
 <li>
 Previous experience in a medical or healthcare setting, preferably a scheduling or administrative role.
 </li>
 <li>
 Familiar with medical terminology, procedures, and insurance verification processes.
 </li>
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 Strong organizational and time management skills, with the ability to multitask and prioritize responsibilities effectively.
 </li>
 <li>
 Ability to read and communicate effectively.
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 <li>
 Strong written and verbal skills.
 </li>
 <li>
 Basic computer knowledge.
 </li>
 <li>
 Ability to manage and demonstrate effective leadership skills.
 </li>
 <li>
 Should demonstrate good interpersonal and communication skills under all conditions and circumstances.Ability to foster a cooperative work environment.
 </li>
 <li>
 Team player with ability to manage multiple responsibilities and demonstrate sound judgment.
 </li>
 </ul>
</div>

Track Case Manager LPN/ RN

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