Registered Nurse Case Manager - Transitions of Care

Central Health•Austin, TX

62d•Onsite

About The Position

The Registered Nurse Case Manager - Transitions of Care is a clinically experienced registered nurse who leads care coordination for patients with complex and chronic medical conditions during transitions between care settings. The role combines clinical judgment, interdisciplinary collaboration, and population health strategies to reduce readmissions, improve outcomes, and address social determinants of health. The RN serves as the clinical lead for a multidisciplinary case management team, including community health workers, and supports continuity of care across inpatient, outpatient, and community environments. This is an onsite position. Only candidates who live or will live in the Austin area will be considered. The role requires regular access to a vehicle to travel to patient locations.

Requirements

Associate Degree in Nursing (ADN) from an accredited School of Nursing.
At least 3 years of clinical nursing experience in a hospital, home health, or ambulatory clinic setting.
At least 2 years of case management experience related to the position's responsibilities.
At least 1 year of experience managing populations with complex medical needs.
Current unrestricted RN license to practice nursing in Texas.
Basic Life Support (BLS) certification obtained through an approved American Heart Association Training Network.
Valid driver's license upon hire.
Knowledge of complex medical conditions and comorbidities.
Ability to work in a complex, dynamic environment with multidisciplinary, cross-functional teams and matrixed team structures.
Strong assessment, critical thinking, and decision-making skills.
Knowledge of social determinants of health and sensitivity to underserved populations.
Familiarity with evidence-based strategies for safe and effective transitions between inpatient, outpatient, and community settings.
Strong communication skills supporting shared decision-making and self-management education.
Strong patient advocacy skills, particularly for vulnerable and underserved populations.
Ability to foster and maintain relationships within the organization and with community partners.
Strong attention to detail and accuracy.
Experience with electronic medical records and healthcare-derived data.
Ability to collaborate with patients, families, and care teams across the healthcare continuum.
Compassion, vulnerability, empathy, and ability to provide patient-centered care grounded in cultural humility.
Must live or be willing to live in the Austin area.
Must have regular access to a vehicle for travel to patient locations.

Nice To Haves

Case Management Certification (CCM).
Accredited Case Manager Certification (ACM).

Responsibilities

Conduct thorough in-person and telephonic assessments, including home visits and clinic accompaniments, to evaluate medical, behavioral health, and functional needs, including social determinants of health and trauma-informed care considerations.
Perform clinical assessments and interventions during patient crises, coordinate emergency services, de-escalate situations, and connect patients with appropriate resources to ensure safety and continuity of care.
Develop and manage individualized, culturally sensitive, evidence-based care plans with measurable goals tailored to complex patient needs.
Coordinate care across medical, behavioral, and social service providers to support continuity, reduce fragmentation, and improve health outcomes.
Apply clinical experience and knowledge of high-risk populations to proactively manage complex cases and reduce disparities.
Lead the case management team as its clinical lead, supporting community health workers and other team members in outreach, engagement, and addressing social needs.
Coordinate with interdisciplinary teams, including physicians, advanced practice providers, specialists, social workers, and community health workers.
Facilitate timely access to primary care, dental, and specialty services for patients with complex medical needs.
Provide disease-specific and medication education, conduct medication reviews, and oversee management of PCP-prescribed medications to support adherence, reconciliation, and access.
Educate and empower patients to use appropriate levels of care, including urgent care and outpatient services, to prevent avoidable emergency room visits.
Use population health strategies, including preventive care and chronic disease management, to improve patient outcomes.
Engage patients and families in shared decision-making, self-management education, and culturally responsive care planning.
Navigate and coordinate community services addressing housing, food insecurity, transportation, financial barriers, and behavioral health access.
Advocate for patients navigating Medicaid, disability, housing, legal aid, and other complex systems and barriers.
Practice AIDET during patient interactions and ensure culturally and linguistically appropriate communication.
Use EHR and population health tools to track outcomes, identify trends, and contribute to quality improvement initiatives.
Precept new clinical team members and students.
Participate in and lead continuous quality improvement projects to improve services for patients, families, and the healthcare system.
Attend staff meetings and education offerings in person and via teleconference or online as required.
Plan and coordinate daily care with Central Health's care team to support quality and efficiency among eligible patients, physicians, advanced practice providers, case management, and nursing.
Support organizational initiatives that promote a strong positive workplace culture.
Adhere to state board of nursing and state nurse practice act requirements and other governing agency regulations.
Maintain regular access to a vehicle for travel to and from patient locations.
Perform other duties as assigned.