Registered Nurse - Transitional Care Manager

Overview

Looking to be part of something more meaningful? At HonorHealth, you'll be part of a team, creating a multi-dimensional care experience for our patients. You'll have opportunities to make a difference. From our Ambassador Movement to our robust training and development programs, you can select where and how you want to make an impact. HonorHealth offers a diverse benefits portfolio for our full-time and part-time team members designed to help you and your family live your best lives. Visit honorhealth.com/benefits to learn more. Join us. Let's go beyond expectations and transform healthcare together. HonorHealth is one of Arizona's largest nonprofit healthcare systems, serving a population of five million people in the greater Phoenix metropolitan area. The comprehensive network encompasses six acute-care hospitals, an extensive medical group with primary, specialty and urgent care services, a cancer care network, outpatient surgery centers, clinical research, medical education, a foundation, an accountable care organization, community services and more. With nearly 17,000 team members, 3,700 affiliated providers and close to 2,000 volunteers dedicated to providing high quality care, HonorHealth strives to go beyond the expectations of a traditional healthcare system to improve the health and well-being of communities across Arizona. Learn more at HonorHealth.com.
Responsibilities

Job SummaryThe Complex and Transitional Care Manager is responsible for managing the care of high-risk, medically complex patients throughout the continuum of care. This includes both chronic condition management and transitional support during care transitions (e.g., hospital discharge, rehab, home care). The goal is to improve clinical outcomes, reduce avoidable readmissions, and support safe, patient-centered care.Job Responsibilities

• Coordinate patient transitions between hospitals, skilled nursing facilities (SNFs), home health, primary care, and specialists.
• Conduct timely patient post-discharge follow-ups via telephonic calls or in-home visits, as warranted.
• Facilitate patient/caregiver education at transitions of care and chronic care management.
• Develop and implement individualized care plans and transition plans in collaboration with patient/caregiver, PCP and embedded Care Coordinators.
• Monitor progress toward goals, adjust care plans as needed, and advocate for access to appropriate services.
• Document assessments, care plans, and interventions in the electronic medical record (EMR) accurately and in a timely manner.
• Collaborate with the Chief Medical Officer, providers, primary care, embedded Care Coordinators and other health care professionals/agencies to ensure complex outpatient care is coordinated across the health care continuum
• Participate in quality improvement initiative related to care transitions, chronic disease management, and utilization reduction.
• Mentors as a buddy for new Care Mangers and Care Coordinators.
• Is key in developing PCP and embedded Care Coordinator relationships and education on Care Management program.
• Maintain all regulatory educational requirements by participating in continuing education activities.
• Demonstrate professional behavior and promotes cooperation and team building.
• Maintain and manage to their caseload
• Support and participate in the development and maintenance of scorecard.
• Maintain accurate metric tracking for daily productivity management.
• Perform other duties or responsibilities as assigned by people leader to meet business needs

Education

• Bachelor's degree in nursing- Required
• Master's degree in nursing - Preferred

Experience

• 2 years as Case (or Care) Manager, Transitional Care Manager, Care Coordinator RN or Nurse Advocate - Required
• 3 Years Registered Nurse - Preferred

License and Certifications

• Registered Nurse (RN) State And /Or Compact State Licensure - Required
• Basic Life Support (BLS) - Required
• Fingerprint Clearance Card - Required
• Certified Case Management (ACM) and/or Certification in Case Management - Preferred
• Certification in Healthcare - nursing or other healthcare field