Hospital Medicine Transition Manager (Nurse Case Manager)

Medrina•West Palm Beach, FL

6d•Hybrid

About The Position

Medrina is hiring a full-time Hospital Medicine Transition Manager (Nurse Case Manager) for a hybrid position based in Palm Beach, Florida. The role works three days per week from the office and also travels to partner sites in the Palm Beach area. Candidates must reside in Palm Beach, Florida. When working from home, the employee must use a private, quiet workspace with a door and reliable internet and phone connectivity. The role requires timely responsiveness during work hours by email, MS Teams, and phone, and participation in virtual meetings with the camera on. Flexible hours and immigration visa sponsorship are not offered. The role coordinates hospital discharges and transitions to post-acute care settings, working with hospital teams, Medrina providers, facilities, patients, and families. It supports timely discharge and continuity of care, addresses placement barriers, tracks transition outcomes, and contributes to quality improvement and value-based care initiatives. The employee documents coordination activities, prepares reports, and ensures compliance with HIPAA, CMS regulations, and organizational policies. The annual salary is $85,000, with a $100 monthly teleworker stipend. Benefits include 15 vacation days, 7 paid holidays, 5 sick days annually, group healthcare benefits beginning on day one, health, dental, and vision plan options, employer-paid life insurance, tuition reimbursement, and a 401(k) with company match.

Requirements

Registered Nurse (RN), Licensed Practical Nurse (LPN), Licensed Clinical Social Worker (LCSW), Social Worker (BSW/MSW), or healthcare professional with equivalent hospital case management experience.
At least 3 years of experience in hospital case management, discharge planning, utilization management, care coordination, or transitions of care.
Strong knowledge of Medicare, Medicare Advantage, Medicaid, and commercial insurance authorization processes.
Understanding of skilled nursing facility admission criteria and post-acute care resources.
Excellent communication, relationship-building, and organizational skills.
Ability to manage multiple priorities in a fast-paced hospital environment.
Must reside in Palm Beach, Florida, USA.
Must be able to work three days per week from the office and travel to partner sites in the Palm Beach area.
Must have a private, quiet home workspace with a door and reliable internet and phone connectivity.
Must be responsive during work hours via email, MS Teams, and phone, and communicate in virtual meetings with the camera on.

Nice To Haves

Certified Case Manager (CCM) or Accredited Case Manager (ACM).
Experience working with hospitalist groups or physician organizations.
Knowledge of value-based care, ACOs, bundled payment programs, or population health.
Experience with hospital electronic medical records such as Epic, Cerner, or Meditech.

Responsibilities

Collaborate daily with hospital case managers, social workers, physicians, and nursing teams to identify patients appropriate for post-acute care.
Coordinate timely discharges to skilled nursing facilities, rehabilitation centers, LTACHs, assisted living facilities, or home, as clinically appropriate.
Identify and address discharge barriers, including insurance authorization, facility acceptance, transportation, clinical documentation, and family concerns.
Facilitate communication between hospital care teams and receiving post-acute providers to support seamless transitions.
Work with Medrina hospital providers to identify discharge opportunities and support patient throughput.
Communicate patient status, anticipated discharge plans, and placement updates to providers.
Coordinate with Medrina post-acute providers to ensure continuity of care after discharge.
Help providers navigate post-acute placement options based on patient needs and preferred facility networks.
Maintain relationships with partner skilled nursing facilities and admissions teams.
Coordinate referrals, facilitate appropriate patient acceptance, monitor bed availability, and communicate placement options to hospital teams.
Ensure clinical documentation and necessary information are transferred promptly to receiving facilities.
Educate patients and families about post-acute care options, discharge expectations, and transition steps.
Address questions and coordinate communication among providers, facilities, patients, and family members.
Support efforts to reduce hospital length of stay and preventable readmissions.
Monitor transition metrics and identify process-improvement opportunities.
Participate in interdisciplinary rounds and discharge-planning meetings.
Escalate complex discharge issues to leadership when appropriate.
Assist with implementing value-based care initiatives and transitional care programs.
Maintain accurate documentation of care coordination activities.
Track referrals, patient transitions, discharge outcomes, and key performance indicators.
Prepare leadership reports on discharge efficiency, placement success, and transition metrics.
Ensure compliance with HIPAA, CMS regulations, and organizational policies.