Registered Nurse / LMSW - Complex & Transitional Care Manager II (ICP)

HonorHealth•Mountain View, AZ

11d•Onsite

About The Position

Great care starts with great people. (Like you.) At HonorHealth, you’ll find something special. From humble beginnings in 1927 to one of Arizona’s largest nonprofit healthcare systems, our culture is built on warmth and neighborly kindness. Behind every smile is a highly skilled professional with deep expertise and an unwavering dedication to what matters most — caring for the health and well-being of people and communities across the greater Phoenix area. JOB SUMMARY 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

Bachelors Nursing Required
2 years as Case (or Care) Manager, Transitional Care Manager, Care Coordinator RN or Nurse Advocate Required
3 years Registered Nurse Preferred
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

Masters Nursing Preferred
Certified Case Manager - Certification Preferred or Accredited Case Manager (ACM) - Certification Preferred
Certification in Healthcare - nursing or other healthcare field 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.
Mentors as a buddy for new Care Mangers and Care Coordinators.
Is key in developing PCP and embedded Care Coordinator relationships and education on Care Management program.
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