Case Mgr RN

Acute Transitional Care Nurse (RN)

Department: Comprehensive Clinical Management Schedule: Monday-Friday, 8 AM-5 PM EST Compensation: $40/hour Location: Remote (with travel as needed)

Job Summary:

The Acute Transitional Care Nurse (RN) plays a key role in coordinating patient transitions across inpatient and outpatient settings. Utilizing advanced nursing expertise, this position ensures quality outcomes, appropriate resource utilization, and seamless continuity of care. The RN collaborates with primary care providers (PCPs) and interdisciplinary care teams in a leadership capacity, aligning evaluations with site-based goals.

Essential Responsibilities:

• Assess and prioritize patient care needs at initial and follow-up encounters.
• Engage patients, families, and caregivers in discussions about treatment plans and care needs.
• Facilitate transitions across acute care, skilled nursing facilities, custodial settings, and ambulatory care.
• Implement established clinical pathways and protocols to optimize patient outcomes.
• Coordinate post-discharge care, including follow-up appointments, home health, and social services.
• Maintain open communication with physicians, care teams, hospitalists, and extended care facilities.
• Apply knowledge of healthcare costs and metrics to support efficient resource utilization.
• Collaborate with providers to ensure successful implementation of patient care plans.
• Coach patients using motivational interviewing techniques to promote self-management.
• Guide discussions on Durable Power of Attorney (DPoA) and advanced directives when appropriate.
• Provide patients and families with accurate information on benefits, community resources, and referrals.
• Accurately document patient information in applicable electronic platforms.
• Work closely with care teams to execute nursing interventions within the appropriate scope of practice.
• Offer remote clinic coverage as needed.
• Travel to meet patients and families per care delivery requirements.
• Perform other duties as assigned.

Required Qualifications:

• Education: Bachelor's degree in nursing (or associate degree in nursing with four or more years of experience).
• Licensure: Active, unrestricted RN license to practice in the state of Florida.
• Experience: Minimum of 2 years of clinical experience in a physician's office, hospital, or healthcare setting.

Preferred Qualifications:

• Prior experience in care continuum management, utilization review, or discharge planning.
• HMO experience preferred.
• CCM Certification is a plus.

Skills & Competencies:

• Strong understanding of patient care standards and professional nursing scope of practice.
• Ability to integrate value-based care principles into clinical practice.
• Valid Florida driver's license and insurance, with the ability to travel as needed.
• Ability to interpret and analyze complex healthcare data and reports.
• Leadership skills with a proactive approach to problem-solving and measurable outcomes.
• Ethical decision-making, professional conduct under pressure, and independent judgment.
• Effective communication skills with patients, families, and healthcare personnel.
• Strong customer service orientation and ability to educate patients.
• Ability to multitask and prioritize in a fast-paced healthcare environment.
• Computer literacy with knowledge of HIPAA regulations.
• Fluent in English (speaking, reading, writing, and comprehension).