RN Case Manager managing transitions from Long-Term Acute Care to lower levels of care. Requires in-person collaboration at LTACs and remote administrative tasks.
Responsibilities
The RN Case Manager – LTAC Transitions facilitates safe, timely, and well-coordinated transitions of patients from Long-Term Acute Care (LTAC) settings to lower—but medically appropriate—levels of care, including skilled nursing facilities, sub acute units, or home and community-based programs.
Working within a hybrid model, the Coordinator spends designated days on-site at partner LTACs to participate in care rounds, engage with discharge planners, and coordinate directly with facility teams, while performing administrative and follow-up tasks remotely on non-onsite days.
This position serves as the operational bridge between LTAC staff, Presidium providers, external facilities, and community partners—ensuring continuity, compliance, and strong communication across all transitions of care.
Complete discharge documentation, coordination notes, and communication logs in the EHR or designated coordination platform.
Arrange logistics including transportation, DME, pharmacy coordination, home health orders, and post-discharge appointments.
Confirm successful transfers and monitor members for 30-day readmission or escalation risk.
Conduct post-transition outreach calls to verify continuity and patient satisfaction.
Maintain compliance with HIPAA, CMIA, and all internal privacy and data security policies.
Requirements
Preferred: Registered Nurse (RN) or equivalent clinical training.
Minimum: Associate degree in Nursing, Health Sciences, Social Services, or related field; or equivalent combination of education and healthcare coordination experience.
Desirable: Bachelor’s degree (BSN, BA/BS in Health Administration, Public Health, or Social Work).
Valid California driver’s license and reliable transportation (for travel to partner LTAC facilities).
Minimum 3 years’ experience in care coordination, discharge planning, or case management within LTAC, acute hospital, SNF, or managed-care environment.
Experience coordinating services and authorizations with health plans, providers, and community partners.
Familiarity with CalAIM, ECM, or Community Supports preferred.
Strong interpersonal skills with the ability to communicate effectively across clinical and administrative teams.
Highly organized with the ability to manage multiple transitions and shifting priorities in a fast-paced environment.
Benefits
3 weeks paid time off (2 weeks + 6-7 federal holidays)
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