Registered Nurse - Complex & Transitional Care Manager Innovation Care Partners

HonorHealth•Scottsdale, AZ

24d•Hybrid

About The Position

The Complex and Transitional Care Manager is responsible for managing the care of high-risk, medically complex patients throughout the continuum of care. This includes both chronic condition management and transitional support during care transitions (e.g., hospital discharge, rehab, home care). The goal is to improve clinical outcomes, reduce avoidable readmissions, and support safe, patient-centered care.

Requirements

License Registered Nurse - New grad Required
1 year as Case (or Care) Manager, Transitional Care Manager, Care Coordinator RN or Nurse Advocate Required
Registered Nurse (RN) - License State And /Or Compact State Licensure Required
Basic Life Support (BLS) - Certification Required
Fingerprint Clearance Card (FPC) - Certificate Required

Nice To Haves

2 years Registered Nurse Preferred
Certified Case Manager - Certification Preferred or Accredited Case Manager (ACM) - Certification Preferred

Responsibilities

Coordinate patient transitions between hospitals, skilled nursing facilities (SNFs), home health, primary care, and specialists.
Conduct timely patient post-discharge follow-ups via telephonic calls or in-home visits, as warranted.
Facilitate patient/caregiver education at transitions of care and chronic care management.
Develop and implement individualized care plans and transition plans in collaboration with patient/caregiver, PCP and embedded Care Coordinators.
Monitor progress toward goals, adjust care plans as needed, and advocate for access to appropriate services.
Document assessments, care plans, and interventions in the electronic medical record (EMR) accurately and in a timely manner.
Collaborate with the Chief Medical Officer, providers, primary care, embedded Care Coordinators and other health care professionals/agencies to ensure complex outpatient care is coordinated across the health care continuum
Participate in quality improvement initiative related to care transitions, chronic disease management, and utilization reduction
Maintain all regulatory educational requirements by participating in continuing education activities.
Demonstrate professional behavior and promotes cooperation and team building.
Maintain and manage to their caseload
Support and participate in the development and maintenance of scorecard.
Maintain accurate metric tracking for daily productivity management.
Perform other duties or responsibilities as assigned by people leader to meet business needs