Job Description

The Registered Nurse Case Manager - Transitions of Care is a clinically experienced registered nurse responsible forleading care coordination for patients with complex and chronic medical conditions during critical transitionsbetween care settings. This role combines advanced clinical judgment, interdisciplinary collaboration, andpopulation health strategies to reduce readmissions, improve outcomes, and address social determinants ofhealth.The RN CM – Transitions of Care serves as the clinical lead for a multidisciplinary case management team, includingcommunity health workers, and plays a pivotal role in ensuring continuity of care across inpatient, outpatient, andcommunity 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, toevaluate medical, behavioral health, and functional needs, including SDOH and trauma-informed careconsiderations.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 withappropriate resources to ensure safety and continuity of care.Develop and manage individualized, culturally sensitive, and evidence-based care plans with measurable goalstailored to complex patient needs.Coordinate care across medical, behavioral, and social service providers to ensure continuity, reducefragmentation, and support optimal health outcomes.Apply clinical experience and knowledge of high-risk populations to proactively manage complex cases and reducedisparities.Lead the case management team, serving as the clinical lead and supporting community health workers and otherson the team in outreach, engagement, and addressing social needs.Coordinate care across interdisciplinary teams including physicians, advanced practice providers, specialists, socialworkers, and community health workers.Facilitate timely establishment of primary care, dental, and specialty services for patients with complex medicalneeds, especially when access is delayed.Provide disease-specific education, medication education, and conduct medication reviews to promote safe andeffective therapy use.Oversee medication management for PCP-prescribed medications, ensuring adherence, reconciliation, and accesssupport.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 patientoutcomes.Engage patients and families in shared decision-making, self-management education, and culturally responsivecare 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 overcomingsystemic 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 qualityimprovement 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 healthcaresystem 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 andefficiency of care between Eligible Patients, Physicians, Advanced Practice Providers, case management andnursing.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 agencyregulations.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-functionalteams and matrixed team structures Strong assessment, critical thinking and effective decision-making skills Knowledge of social determinants of health issues and demonstrate sensitivity to underservedpopulations 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 communitypartners 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) - Required

Work Experience:

3 years Clinical nursing experience in a hospital, home health or ambulatory 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- Required

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

Case Management Certification Case Management Certification (CCM) -PreferredAccredited Case Manager Accredited Case Manager Certification (ACM) -Preferred