Registered Nurse - Case Manager

Local rate is -$3 and considered within 75 miles of facility. Hours: 8-4pm. Occasional weekends.

NY State RN License in Hand Bachelor's Degree required 3yrs of ambulatory experience preferred Epic exp preferred The position will support a new program that the Quality Department is putting in place General

• The Transitional Care Management (TCM) Registered Nurse (RN) is responsible for coordinating and managing patient care transitions following discharge from an inpatient facility, emergency department, skilled nursing facility, or other care settings. The TCM RN works collaboratively with providers, practice staff, patients, caregivers, and community resources to reduce readmissions, improve patient outcomes, support quality performance measures, and ensure timely follow-up care in alignment with value-based care initiatives. The TCM RN utilizes evidence-based practices, population health strategies, and High Reliability Organization (HRO) principles to ensure safe, efficient, and patient-centered Duties/Responsibilities: Transitional Care Management
• Conduct outreach to discharged patients within required timeframes (typically within 48 business hours of discharge).
• Complete comprehensive post-discharge assessments including: o Medication reconciliation o Review of discharge instructions o Identification of barriers to care o Evaluation of symptoms and clinical concerns
• Coordinate and schedule timely follow-up appointments with Primary Care Providers (PCP) and specialists.
• Ensure completion of TCM documentation requirements in EPIC.
• Monitor high-risk patients for complications, worsening symptoms, or readmission risk.
• Escalate clinical concerns to providers promptly using appropriate communication tools (SBAR). o Assessment of social determinants of health Care Coordination
• Collaborate with physicians, advanced practice providers, nurses, social workers, care managers, and hospital liaison to ensure continuity of care.
• Facilitate referrals for home care, behavioral health, palliative care, pharmacy support, or community resources as needed.
• Assist patients and caregivers in understanding diagnoses, medications, treatment plans, and self-management strategies.