Onsite Inpatient Case Manager: (RN, LPN, SW)- Sarasota/Lakewood Ranch

MAXhealth•Sarasota, FL

4d•Onsite

About The Position

The Onsite Inpatient Case Manager is responsible for being onsite at hospitals to coordinate and manage care transitions for patients following ED, hospitalization or skilled nursing facility stays. The Case Manager works onsite with clinical teams, providers, and community partners to ensure safe, timely, and effective care transitions that reduce readmissions, ED Diversion, and works to improve patient outcomes and experience.

Requirements

RN, LPN, SW, or other licensed healthcare professional required.
Minimum 3 years of clinical or case management experience
Three years in a professional setting such as hospital, clinic setting, or Managed Care Organization
Proficiency with computers, experience in basic office programs and EMR or EHR systems.

Nice To Haves

Experience in care transitions, population health, or chronic disease management preferred.
Experience related to case management, utilization management, quality assurance, discharge planning or other cost management program preferred
Experience working with Medicare Advantage Population preferred

Responsibilities

Conduct face-to-face or bedside visits with attendings, patients and care team prior to discharge to assess needs, barriers, and risks.
Develop and implement individualized transitional care plans in collaboration with providers, hospital discharge planners, and caregivers.
Ensure timely post-discharge scheduling of follow-up appointments within 3 days as appropriate.
Coordinate medication reconciliation and education with pharmacists or nursing staff.
Identify and address social determinants of health impacting recovery or self-management.
Monitor patient progress during the 30-day post-discharge period, providing outreach, coaching, and coordination as needed.
Maintain documentation in the electronic health record (EHR) according to TCM and organizational standards.
Track outcomes such as readmissions, ER visits, and follow-up adherence using population health tools.
Serve as liaison between inpatient and outpatient care teams, ensuring effective communication and continuity of care.