• Elevance Health (Arlington, VA)
    Anticipated End Date: 2025-08-18 Position Title: Licensed Transition of Care Specialist, VA Foster Care (North Region) Job Description: LOCATION: This is a ... work-life integration, and ensures essential face-to-face onboarding and skill development. The Transition of Care Specialist (Special Programs Case Mgr I) works… more
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  • Monogram Health (Newark, NJ)
    Position: Transition of Care Manager The Transition of Care Manager reports directly to the Market Physician Executive (MPE) within their Pod and is ... for engaging with Monogram's attributed patients and their families in inpatient facilities . This role's primary responsibility is to find, engage and enroll new… more
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  • Option Care Enterprises, Inc. (Fairfax, VA)
    …information and communicates this to patient registration department. Proactively initiates care transition coordination with referral sources and internal ... the patient and proper assessment and treatment process and transition to home care . Serves as a...transportation which will enable the incumbents to travel to care facilities , home visits and multiple hospitals.… more
    Upward (07/19/25)
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  • VitalCaring Group (West Palm Beach, FL)
    …Paid Time Off Pet Insurance Tuition & Continuing Education Reimbursement As a Care Transition Navigator, you will: Cultivate and nurture relationships with ... post transition needs are addressed to ensure a safe and effective transition home Facilitate thorough communication between care team members to enhance the… more
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  • Pioneer Healthcare (Wichita, KS)
    …discharge planning to ensure a smooth transition to home or other care settings. Qualifications: KS Registered Nurse License Basic Life Support (BLS) ... want to make a significant impact as a Registered Nurse - Medical Surgical in Wichita, KS this position...practitioners, and other healthcare professionals to develop and implement care plans, and communicate effectively with patients and their… more
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  • Trinity Health - IHA (Rochester, MI)
    …experience with primary care /ambulatory care , home health agency, skilled nursing facility , or hospital medical-surgical, within the past five years. ... care coordination for patients that are experiencing a transition of care , undergoing treatment or have...program. ESSENTIAL QUALIFICATIONS: EDUCATION: Bachelor of Science degree in Nursing (BSN) or Associates Degree in Nursing more
    Upward (07/18/25)
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  • UnitedHealth Group (Eden Prairie, MN)
    …optimal transitions of care . Actively supports ED discharge follow-up care utilizing approved clinical guidelines to transition and provide continuity ... License. Primary Responsibilities: Independently collaborates effectively with ED and outpatient care teams to establish an individualized transition plan for… more
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  • Kaiser Permanente (Clackamas, OR)
    care ) ICU (hospital acute care ) Emergency Department Home Health Skilled Nursing Facilities Hospice Long Term Acute Care Inpatient Rehab Utilization ... of Medicare and Medicaid regulations related to eligibility requirements: hospital, nursing facilities , home health, hospice, and Durable Medical Equipment… more
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  • The Jane Pauley Community Health Center, Inc (Greenfield, IN)
    …disease prevention and management, teaching and education, developing nursing care plans, and communicating with external facilities and patient's families. ... to JPCHC and between internal teams and external healthcare facilities including referrals from the primary care ...and use of health information exchange. Collaborate with the Care Team for smooth transition of … more
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  • AdventHealth (Ocala, FL)
    …up appointments, Skilled Nursing Facilities , Rehabilitation Services and Facilities and Community-based Organizations. The RN Care Manager adheres to ... Care Managment Supervisor or Manager or Director of Nursing and is responsible for patient evaluations of post-hospital...for patient evaluations of post-hospital needs; development of a transition of care plans and initiation of… more
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  • ERIE FAMILY HEALTH CENTER (Chicago, IL)
    …and documentation for patients transitioning between the hospital, Emergency Department, Skilled Nursing Facilities , home, and other care settings. ... reflected in the compensation offered. Main Duties & Responsibilities Conducts transition of care outreach to patients or individuals supporting their care more
    Upward (07/10/25)
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  • Option Care Enterprises, Inc. (Jupiter, FL)
    …a reliable means of transportation which will enable the incumbents to travel to care facilities , home visits and multiple hospitals. If such means of ... for providing clinical education and training to ensure successful transition of patients to an Option Care ... of patients from hospital to home or alternate care settings by collaborating with facility staff,… more
    Upward (07/21/25)
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  • BAYADA Home Health Care (Gaithersburg, MD)
    …for your clients Work closely with your home health therapy partners to appropriately transition care from home health to outpatient services in order to achieve ... patients on a per visit basis in Senior Living Facilities throughout Montgomery County. As a home care...multi-disciplinary health care team that provides rehabilitative care and skilled nursing to clients, affording… more
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  • Memorial Healthcare System (Pembroke Pines, FL)
    …of the patient's needs, clinical, psychosocial, and financial are adequately addressed in the transition of the care plan and to manage the patient's timely ... Career opportunities exist on diverse teams across our many facilities where you can search open positions and apply...progression of care and safe transition to the next… more
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  • Alternate Solutions Health Network (Cleveland, OH)
    …settings within the health system to share your expertise and to assist the patient in transition of care from one setting to the next within the health system. ... facility manager before contacting patients. Operations: Participate in Care Integration meetings. HARD & SOFT SKILLS: Compassionate communicator with a… more
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  • UnitedHealth Group (Clinton, MS)
    …Coordinator- Onsite is responsible for ensuring efficient, smooth, and prompt transitions of care Perform Skilled Nursing Facility (SNF) assessments on ... of dedicated visionary leaders and innovative organizations challenging the status quo for care transition solutions. We do health care differently and… more
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  • Lehigh Valley Health Network (Allentown, PA)
    …you should consider Lehigh Valley Health Network. Summary Provides professional nursing care through skillful assessment, diagnosis, outcomes identification, ... provides patient and family education throughout treatment course to facilitate an effective transition of care . Functions as a department team member to support… more
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  • Actalent (Detroit, MI)
    …6. Provides coordination as necessary to ensure patients seamlessly and safely transition between care settings. 7. Advocates for appropriate delivery of ... planning of patients either from the hospital to their home or another medical facility . The EMR (electronic medical records) system they use is EPIC however it is… more
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  • Elevance Health (Ashburn, VA)
    …essential face-to-face onboarding and skill development. The Nurse Case Manager I ( Transition of Care ) is responsible for performing care management ... Anticipated End Date: 2025-07-27 Position Title: RN Nurse Case Manager I Job Description: LOCATION: This...in an inpatient setting, home health and/or a skilled/long-term nursing facility is a must for this… more
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  • Commonspirit Health (Houston, TX)
    …Assessment: Does admission and ongoing assessment of patient's condition. Provides nursing care to meet the patient's physical, psychological and ... intervals following interventions. Notifies physician as necessary to modify interventions. Adjusts nursing care to meet patient's emerging and changing needs.… more
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