Rn transition coordinator

Embedded Transitional Care Manager RN

Oak Street Health takes a team-based approach to providing outstanding patient c...

Location

United States , Rockford

Salary:

66575.00 - 142576.00 USD / Year

CVS Health

Expiration Date

Until further notice

Requirements

An active RN license within the state of practice in good standing
Willingness to obtain cross-state licensure, as needed
Certified Case Manager (CCM) or equivalent case management certification required, or willingness to obtain within 12 months of hire
2+ years’ experience in transitional nursing, discharge planning, nursing case management, or home health
Experience in utilization management preferred
Knowledge of Medicare/Medicaid and NCQA regulatory transitions of care criteria
Exceptional communication skills and customer service orientation
Innovative and independent problem solving skills
Ability to monitor and evaluate opportunities for cost-effective care options with high-quality outcomes
Spanish-speaking preferred but not required

Job Responsibility

Manage patients through transitions of care
Advocate for the patient throughout the care continuum
Identify opportunities for improved program workflows
Maintain real-time and accurate records of patient status
Adhere to CMS, state specific and NCQA compliance criteria
Evaluate patient status post-ED visit or observation stay
Triage to determine appropriate follow up care
Engage directly with inpatient physicians, case managers, medical directors, and hospitalists
Coordinate with the Utilization Management team
Conduct structured clinical assessment to identify post-discharge needs

What we offer

Paid vacation, sick time, and investment/retirement 401K match options
Health insurance, vision, and dental benefits
Affordable medical plan options
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access

Fulltime

Care Transitions Coordinator RN/LPN Clinical Sales

Are you looking for a rewarding career as a care transitions coordinator? If so,...

Location

United States , Rosedale

Salary:

85000.00 - 90000.00 USD / Year

Amedisys

Expiration Date

Until further notice

Requirements

At least one year of experience in a healthcare related business development/outreach role
Current RN or LPN license, specific to the state(s) you are assigned to work
Reliable transportation, current driver's license, and liability insurance
This role will travel 50% or more within the assigned territory

Job Responsibility

Educates health care professionals, patients, and families about home care services
Develops and maintains relationships with key referral sources, such as hospitals, nursing homes and physician offices to generate leads
Coordinates patient admissions with the team, including obtaining all required documentation to complete referral to admission process
Conducts on-site visits to assess patient needs and identify barriers to care
Keeps accurate records of patient interactions and referrals
Achieves admissions, product, and payor-mix goals
Meets short and long-term target account goals
Documents the minimum expectation of sales calls daily in CRM (including pre and post call notes)
Maintains a complete, up-to-date record of targeted referral sources in territory in CRM
Attends community events to promote Amedisys

What we offer

A full benefits package with choice of affordable PPO or HSA medical plans
Paid time off
Up to $1,000 in free healthcare services paid by Amedisys yearly, when enrolled in an Amedisys HSA medical plan
Up to $500 in wellness rewards for completing activities during the year
Mental health support, including up to five free counseling sessions per year through the Amedisys Employee Assistance program
401(k) with a company match
Family support with infertility treatment coverage, adoption reimbursement, paid parental and family caregiver leave
Fleet vehicle program (restrictions apply) and mileage reimbursement

Fulltime

Embedded Transitional Care Manager

The Embedded Transitional Care Manager - RN (TCM-RN) plays a critical role in en...

Location

United States , Indianapolis

Salary:

54095.00 - 116760.00 USD / Year

CVS Health

Expiration Date

Until further notice

Requirements

An active RN license within the state of practice in good standing
willingness to obtain cross-state licensure, as needed
Certified Case Manager (CCM) or equivalent case management certification required, or willingness to obtain within 12 months of hire
2+ years’ experience in transitional nursing, discharge planning, nursing case management, or home health
experience in utilization management preferred
knowledge of Medicare/Medicaid and NCQA regulatory transitions of care criteria
exceptional communication skills and customer service orientation
innovative and independent problem-solving skills
ability to monitor and evaluate opportunities for cost-effective care options with high-quality outcomes
Spanish-speaking preferred but not required

Job Responsibility

Manage patients through transitions of care, either face to face in the facility or telephonically
advocate for the patient throughout the care continuum
identify opportunities for workflow improvements and partnerships
maintain real-time records of patient transitions
engage with physicians, case managers, and hospitalists
coordinate follow-up care, medication reconciliation, and discharge planning
collaborate with internal stakeholders and regional leaders on transitions initiatives
participate in training, documentation, tracking, and quality assurance

What we offer

Mission-focused career
paid vacation and sick time
investment/retirement 401K match options
health insurance, vision, and dental benefits
affordable medical plan options
no-cost programs for health and wellness
tuition assistance
flexible schedules
family leave
dependent care resources

Fulltime

New

Weekend position. Saturday and Sunday 8a - 6p. Must also be able to join 30 minu...

Location

United States , Charlotte

Salary:

38.20 - 57.30 USD / Hour

Advocate Health Care

Expiration Date

Until further notice

Requirements

Graduate of an accredited school of nursing required
BSN preferred
Current RN license or temporary license as a Registered Nurse Petitioner in the state in which you work and reside
Minimum of three years nursing experience preferred
Prefer two years in acute health care inpatient setting
home health, managed care, hospice, or case management
Current driver's license

Job Responsibility

Functions as a liaison for patient/family in navigating the continuum of care
Assesses, plans, coordinates, and evaluates services of patients with the goal of equipping and empowering individuals and their families to easily assess resources and adopt healthy lifestyles
Works closely with hospitals, clinics, health care facilities, and agency clinical and administrative personnel to ensure patient care is seamless, efficient, effective and appropriate
Interacts daily with patients, medical professionals, and the community to achieve continuity of care, coordination of medical services, and to document plans of care as related to home health care and hospice services
Makes on-site consultative, educational visits in the hospital to evaluate the appropriateness of the patient's admission to continuing care services
Completes accurate and appropriate documentation, logs, and/or patient forms and records to ensure compliance with regulations, agency policy, payer requirements, and standards of care

What we offer

Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program

Parttime

New

Tcp coordinator

Coordinate TCP & STRC services, ensuring safe, timely, person-centred support. G...

Location

Australia , Underdale

Salary:

Not provided

Southern Cross Support Services

Expiration Date

Until further notice

Requirements

Current AHPRA registration as an RN or EN (no conditions)
Certificate III/IV in Aged Care, Community Services, or similar (or currently working towards one)
Strong understanding of the aged care sector, My Aged Care portals, referral pathways, and community support
Excellent communication and stakeholder management skills
Strong organisational skills with the ability to prioritise competing deadlines
Current Driver’s Licence with reliable vehicle
Hold or willing to obtain: National Police Clearance & Working with Children Check

Job Responsibility

Care Coordination & Assessment: Coordinate client assessments, develop care plans, and ensure supports align with TCP/STRC program requirements
Hospital & Stakeholder Liaison: Work with hospital teams, discharge planners, and clinicians to ensure smooth transitions and clear communication
Client Support & Monitoring: Maintain regular contact with clients and families, review progress, and adjust care plans as needed
Service Coordination: Arrange services with internal teams and external providers to ensure timely, safe, and effective support delivery
Documentation & Reporting: Maintain accurate records, complete required program documentation, and manage reporting and invoicing tasks
Risk & Compliance: Identify and report risks or incidents, promoting safe practices in line with program and organisational standards

What we offer

A supportive, close-knit team that values your contributions
Wellness initiatives and access to the Sonder wellbeing app – 24/7 support
Monthly RDOs, giving an additional 12 days of leave per year
Flexible work arrangements to support work-life balance
Employee recognition programs, including Employee of the Month and service awards
Genuine opportunities for career growth and progression

Fulltime

New

Director, RN Case Management

The Director, RN Case Management provides strategic and operational leadership f...

Location

United States , Denver, Colorado

Salary:

115700.00 - 150500.00 USD / Year

InnovAge

Expiration Date

Until further notice

Requirements

Bachelor’s degree in Nursing (BSN)
Current state-issued Registered Nurse (RN) license
5+ years of experience in acute care coordination, case management, or discharge planning
2+ years of leadership or supervisory experience in a clinical setting
Demonstrated success in performance management, operational execution, and cross-functional collaboration
Experience in quality improvement, compliance adherence, or care coordination oversight

Job Responsibility

Leads, develops, and supports RN Case Managers, including recruitment, onboarding, coaching, and performance management
Establishes division-wide workflows, standards, and best practices for acute and post-acute care coordination
Partners with the VP of Nursing Operations and clinical leadership to implement staffing strategies, workload balancing, and coverage expectations for case management services
Oversees daily operational execution of case management functions, ensuring timely coordination, documentation, and communication across care teams
Ensures RNs receive training and ongoing development to maintain clinical competency in transitional care and utilization management
Oversees the experience of participants during hospitalization and post-acute stays, ensuring high-quality transitions and strong communication
Responds to escalated participant concerns in coordination with Center Directors, providers, and Quality teams
Ensures RN Case Managers collaborate effectively with participants, families, caregivers, and IDT members to support person-centered care plans
Monitors service KPIs and drives improvements in communication, responsiveness, and participant satisfaction during transitional care periods
Ensures division performance aligns with quality metrics related to readmissions, skilled days, length of stay, and transition-of-care outcomes

What we offer

medical/dental/vision insurance
short and long-term disability
life insurance and AD&D
supplemental life insurance
flexible spending accounts
401(k) savings
paid time off
company-paid holidays

Fulltime

Registered Nurse – Hospice Admission

This is a community-based role and will require regular travel in local and rura...

Location

United States , Tucson

Salary:

Not provided

Tucson Medical Center

Expiration Date

Until further notice

Requirements

Graduation from a qualified, nationally-accredited nursing program
One (1) year of nursing experience in an acute care setting
Current RN licensure permitting work in the State of Arizona
Basic Life Support (BLS) certification required
For Outpatient Hospice & Pediatrics areas, valid Arizona Fingerprint Clearance Card within 6 months of hire
Must have access to a vehicle, a valid driver's license, and current insurance
Knowledge of direct patient care and critical care procedures and techniques
Knowledge of the death/dying and bereavement process
Skill in communicating in a clear and concise manner
Ability to read and interpret documents such as safety rules and procedure manuals

Job Responsibility

Provides patient assessments in various settings to facilitate a well-coordinated, smooth transition to TMC Hospice services
Obtains initial medical orders from the referring providers
Assists Intake Department with referral, computer input as needed
Supports the death/dying process
Promotes TMC Hospice services and programs and exceptional customer service to physicians, facility staff, patients, and families
Develops and maintains positive relationships with referral sources
Explains hospice services and benefits to patients, family members, and caregivers
Develops and maintains therapeutic connections and relationships
Performs a comprehensive nursing assessment
Directs and efficiently coordinates the initiation of hospice services, and any other equipment, supplies, external services for hospice clients

Parttime

Registered Nurse – Hospice Admission

This is a community-based role and will require regular travel in local and rura...

Location

United States , Tucson

Salary:

Not provided

Tucson Medical Center

Expiration Date

Until further notice

Requirements

Graduation from a qualified, nationally-accredited nursing program
One (1) year of nursing experience in an acute care setting
Current RN licensure permitting work in the State of Arizona
Basic Life Support (BLS) certification required
For Outpatient Hospice & Pediatrics areas, valid Arizona Fingerprint Clearance Card within 6 months of hire
Must have access to a vehicle, a valid driver's license, and current insurance
Knowledge of direct patient care and critical care procedures and techniques
Knowledge of the death/dying and bereavement process
Skill in communicating in a clear and concise manner
Ability to read and interpret documents such as safety rules

Job Responsibility

Provides patient assessments in various settings to facilitate a well-coordinated, smooth transition to TMC Hospice services
Obtains initial medical orders from the referring providers
Assists Intake Department with referral, computer input as needed
Supports the death/dying process
Promotes TMC Hospice services and programs and exceptional customer service to physicians, facility staff, patients, and families
Develops and maintains positive relationships with referral sources
Supports programs, organizational, and departmental policies, goals, and objectives
Explains hospice services and benefits to patients, family members, and caregivers
Develops and maintains therapeutic connections and relationships
Performs a comprehensive nursing assessment

Fulltime

Rn transition coordinator - transition services

Advocate Health Care

Location:
United States , Charlotte

Category:
Nursing

Contract Type:
Not provided

Salary:

Job Description:

Job Responsibility:

Requirements:

Additional Information:

Job Posted:
February 11, 2026

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