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DMC Primary Care
Overview
The Transitional Care Specialist supports patients moving from inpatient or rehab settings back to primary care by coordinating follow-up care and conducting outreach. They focus on reducing avoidable readmissions through clinical assessments and communication between care teams.
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Compensation
Salary not listed
Posted
15 days ago
Cleveland Clinic
Responsibilities include completing comprehensive patient assessments upon arrival, initiating and reviewing individualized plans of care, accurately administering medications, and serving as a patient/family advocate to facilitate care and resolve issues. The role also involves participating in discharge planning, communicating patient status updates, and functioning in triage nurse positions as required.
29 days ago
Brown Medicine
The Case Manager facilitates patient care services by collaborating with the healthcare team to develop and implement effective discharge plans. They identify high-risk patients, monitor care delivery, and ensure compliance with federal and state regulations throughout the patient's stay.
$90,418 - $146,640 / YEAR
1 month ago
American Addiction Centers
Provide and coordinate comprehensive patient care through the nursing process to deliver safe, therapeutic mental health services. Collaborate with a multidisciplinary team to perform crisis assessment, stabilization, and transition planning for patients.
$38 - $57 / HOUR
FLACRA
The Transition Care Coordinator supports patient health outcomes by navigating and coordinating clinical and non-clinical services for behavioral and mental health needs. Responsibilities include conducting outreach, facilitating discharge planning, and assisting clients with appointments to ensure successful engagement in the healthcare system.
$19 - $20 / HOUR
2 months ago
The Case Manager facilitates and coordinates patient care services across the continuum, including preadmission and post-hospital discharge planning. They collaborate with the interdisciplinary healthcare team to ensure efficient resource utilization and safe patient transitions.
$80,330 - $160,618 / YEAR
ChristianaCare
The RN Case Manager manages patient care, drives patient progression, and establishes comprehensive discharge plans. They collaborate with an interdisciplinary team to monitor treatment plans and ensure effective transitions throughout the care continuum.
$60 / HOUR
Memorial Regional Health
This role involves tracking patient cases from admission to discharge, developing individualized care plans, and ensuring patients are appropriately qualified and connected with necessary follow-up resources. The position also requires conducting utilization review by gathering clinical information to confirm medical necessity and appropriate levels of care, while advocating for the patient's needs with providers and insurers.
$34 - $50 / HOUR
Orlando Health
Provide comprehensive medical care to adolescents and young adults with complex medical conditions during their transition from pediatric to adult healthcare. Coordinate seamless transitions by collaborating with multidisciplinary teams and developing individualized care plans.
HonorHealth
The Care Manager RN Heart Failure Coordinator plans, organizes, and arranges services for Heart Failure (HF) patients by collaborating with the healthcare team and providing guidance on medication reconciliation, post-discharge needs, and self-management support. This role focuses on ensuring a smooth transition from hospital to outpatient care by coordinating across the health care continuum, including follow-up care and communication between various providers.
Triad Adult and Pediatric Medicine, Inc
This role serves as a Community Health Outreach Worker, connecting formerly incarcerated participants with essential health information and healthcare services while assisting in navigating those systems. The worker will also identify and help address social drivers of health such as housing, employment, and food barriers to successful societal re-engagement.
3 months ago
Healthforce by TLC
Key responsibilities involve delivering person-centered nursing care aligned with resident care plans, including administering medications, monitoring vitals, observing condition changes, and documenting findings in electronic health records. The role also requires collaborating with the interdisciplinary team, educating residents and families, and participating in rounds and discharge planning.
$989 - $1,060 / WEEK
This role involves tracking patient cases from admission to discharge, developing individualized care plans, and ensuring patients access necessary follow-up resources, including conducting appeals for service denials. The position also requires conducting utilization reviews by gathering clinical information, interpreting criteria to ensure medical necessity, and coordinating smooth transitions for transfers or discharges.
4 months ago
