RN Care Manager - Transitions of Care

The RN Care Manager-Transitions of Care is a member of the population health team focused on coordination of care of patients in transition between the hospital, emergency department, skilled nursing facility (SNF), and primary care setting. Primary responsibility includes working with teams within our local hospitals, health plans, SNFs, community based organizations (CBOs), and Tiburcio Vasquez Health Center (TVHC) to keep patients healthy upon their return home. Through this work, we will be able to prevent unnecessary readmissions and emergency department visits post-discharge. Under the general direction of the Senior Director of Population Health, the RN Care Manager-Transitions of Care monitors the daily ADT (admissions, discharges, and transfers) information to identify patients in need of post-discharge follow up and facilitates care with the assigned care teams, specialists, and CBOs.

The RN Care Manager-Transitions of Care may oversee clinical...