Healthcare Transition Specialist

2 days ago


Cincinnati, Ohio, United States CommuniCare Family of Companies Full time

About CommuniCare Family of Companies

We are a leading provider of healthcare services, dedicated to improving patient outcomes and quality of life. Our team of experts is committed to delivering exceptional care and support to our patients and their families.

Job Summary

We are seeking a highly skilled RN Transitional Care Manager to join our team. The successful candidate will be responsible for managing the transition of patients from skilled nursing facilities to hospitals and back again, ensuring seamless care coordination and minimizing unnecessary complications.

Key Responsibilities

  • Coordinate discharge planning and post-discharge care with hospital and facility teams
  • Facilitate communication and handoff with care managers and interdisciplinary teams to ensure continuity of care
  • Provide telephonic support and management to case managers and nurse practitioners on complex cases
  • Serve as a subject matter expert (SME) for case managers and nurse practitioners on transitional care best practices
  • Complete handoff forms with clinical supplementation, updated medication reconciliation, and case management recommendations
  • Identify potential issues that may lead to complications during care transitions and implement strategies to prevent them
  • Collaborate with hospital discharge planners to implement discharge plans back to patient facilities
  • Work with utilization management departments to determine appropriateness of stay and prevent unnecessary admissions
  • Maintain knowledge of Medicare benefits, plan benefits, and community resources to provide optimal patient care

Qualifications and Experience

  • Licensed Registered Nurse (RN) with experience in physical and behavioral health case management, preferably in an integrated setting
  • Minimum 3-5 years of case management experience, with a focus on transitional care
  • Experience in Medicare Advantage programs and health coaching is a plus
  • Ability to utilize various applications and databases to fulfill care management requirements and documentation

Salary and Benefits

The estimated salary for this role is $85,000 - $110,000 per year, depending on experience. Our comprehensive benefits package includes medical, dental, and vision insurance, 401(k) matching, and paid time off.



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