Job Description

The Registered Nurse Case Manager - Transitions of Care is a clinically experienced registered nurse responsible for leading care coordination for patients with complex and chronic medical conditions during critical transitions between care settings. This role combines advanced clinical judgment, interdisciplinary collaboration, and population health strategies to reduce readmissions, improve outcomes, and address social determinants of health.The RN CM – Transitions of Care serves as the clinical lead for a multidisciplinary case management team, including community health workers, and plays a pivotal role in ensuring continuity of care across inpatient, outpatient, and community environments.

This is an onsite position. Only candidates that live or will live in the Austin area will be considered for this role.

Responsibilities

Essential Functions:

• Perform thorough in-person and telephonic assessments, including home visits and clinic accompaniments, to evaluate medical, behavioral health, and functional needs, including SDOH and trauma-informed care considerations.
• Perform clinical assessments and interventions during patient crises (e.g. homelessness, substance use, psychiatric episodes, etc.). Coordinate emergency services, de-escalate situations, and connect patients with appropriate resources to ensure safety and continuity of care.
• Develop and manage individualized, culturally sensitive, and evidence-based care plans with measurable goals tailored to complex patient needs.
• Coordinate care across medical, behavioral, and social service providers to ensure continuity, reduce fragmentation, and support optimal health outcomes.
• Apply clinical experience and knowledge of high-risk populations to proactively manage complex cases and reduce disparities.
• Lead the case management team, serving as the clinical lead and supporting community health workers and others on the team in outreach, engagement, and addressing social needs.
• Coordinate care across interdisciplinary teams including physicians, advanced practice providers, specialists, social workers, and community health workers.
• Facilitate timely establishment of primary care, dental, and specialty services for patients with complex medical needs, especially when access is delayed.
• Provide disease-specific education, medication education, and conduct medication reviews to promote safe and effective therapy use.
• Oversee medication management for PCP-prescribed medications, ensuring adherence, reconciliation, and access support.
• Educate and empower patients to access appropriate levels of care, including urgent care and outpatient services, to prevent avoidable emergency room visits.
• Utilize population health strategies such as preventive care and chronic disease management to improve patient outcomes.
• Engage patients and families in shared decision-making, self-management education, and culturally responsive care planning.
• Navigate and coordinate community-based services to address social determinants of health, including housing, food insecurity, transportation, financial barriers, and behavioral health access.
• Advocate for patients in navigating complex systems (Medicaid, disability, housing, legal aid) and overcoming systemic barriers.
• Enhance the patient experience by practicing AIDET during each patient interaction.
• Ensure culturally and linguistically appropriate communication with patients.
• Leverage EHR and population health tools to track outcomes, identify trends, and contribute to quality improvement initiatives.
• Serve as a preceptor for new clinical team members and students.
• Participate and lead continuous quality improvement projects to better serve the patient, family and healthcare system to improve the quality of service provided.
• Attend staff meetings and education offerings in person and via teleconference/online as required.
• Plan and coordinate care daily with all members of Central Health’s care team to assure maximum quality and efficiency of care between Eligible Patients, Physicians, Advanced Practice Providers, case management and nursing.
• Support organizational initiatives to promote and maintain a strong positive workplace culture.
• Adhere to state board of nursing and state nurse practice act requirements and to other governing agency regulations.
• Must have regular access to a vehicle to travel to and from patient locations.
• Perform other duties as assigned.

Knowledge, Skills and Abilities:

• High knowledge of complex medical conditions and co morbidities
• Ability to thrive in a complex and dynamic work environment with multidisciplinary, cross-functional teams and matrixed team structures
• Strong assessment, critical thinking and effective decision-making skills
• Knowledge of social determinants of health issues and demonstrate sensitivity to underserved populations
• Familiarity with evidence-based strategies to ensure safe and effective transitions between inpatient, outpatient, and community settings.
• Strong communication skills to support shared decision-making and self-management education.
• Strong patient advocacy skills, especially for vulnerable and underserved populations.
• High level skill at fostering and maintaining relationships within the organization and community partners
• Strong attention to detail and accuracy
• Experience with electronic medical records and healthcare-derived data
• Ability to collaborate with patients, families and care teams across the health care continuum.
• Exhibit compassion, vulnerability, and empathy.
• Provide patient centered care that is inclusive and focuses on cultural humility

Qualifications

Minimum Requirements for role:

Education:

Graduation from an accredited School of Nursing with an Associate Degree in Nursing (ADN)

Work Experience:

Minimum of (3) three years of clinical nursing experience in a hospital or clinic setting -Required

2 years Case management experience as it relates to responsibilities of the position -Required

1 year Experience managing populations with complex medical needs -Required

Licenses/Certifications:

Current unrestricted RN license to practice nursing in the State of Texas -Required

Basic Life Support (BLS) - Obtained through approved American Heart Association Training Network or American Red Cross. -Required

Driver's License -Valid Driver's License -Upon Hire -Required