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RN Care Transition Manager

  • Rhode Island, Providence

  • 04/09/2026

  • Contract

  • Active

Job Description:

  • Job Summary
    We are seeking an RN Care Transition Manager to support the Transitions of Care team by conducting telephonic follow-up with patients transitioning out of acute care settings. This temporary bridge assignment ensures compliance with payer contract requirements, NCQA timeliness benchmarks, and quality standards. The role is entirely phone-based and requires collaboration with physicians, care coordinators, social workers, and patients to ensure appropriate community resources are in place.

    Key Responsibilities
    1. Conduct post-hospital and ED follow-up phone calls within required timeliness windows (including 48-hour TCM calls).
    2. Apply Case Management principles to acute care inpatient populations to ensure appropriate utilization of resources and level of care.
    3. Facilitate discharge planning for Integra ACO patients, including referrals to skilled nursing, home health, outpatient providers, and infusion therapy.
    4. Identify barriers to patient flow and collaborate with the interdisciplinary team to resolve them.
    5. Identify patients requiring Case Management and Social Service referrals.
    6. Complete all documentation accurately and timely in Epic and Cerner.
    7. Act as a resource to the ED Hospital Liaison.
    8. Support process improvement efforts to reduce unnecessary admissions, lower readmission rates, and improve flow metrics.
    9. Maintain patient confidentiality in compliance with HIPAA at all times.

    Required Qualifications
    • Active, unencumbered Registered Nurse (RN) licensure in Rhode Island.
    • Med/Surg RN background strongly preferred.
    • Minimum 5 years of related clinical experience in Acute Care or Case Management.
    • Knowledge of utilization review, discharge planning, and third-party payor regulations.
    • Strong interpersonal, oral, and written communication skills.
    • Demonstrated analytical ability, leadership, and effectiveness in team environments.

    Preferred Qualifications (if any)
    • Experience in telephonic case management or Transitions of Care.
    • Familiarity with Epic and/or Cerner documentation systems.
    • Bachelor’s Degree in Nursing (BSN) or equivalent.
    • Previous care management experience (preferred but not required).

    Certifications (if any)
    1. Active RN license in Rhode Island required.
    2. BSN or case management certification preferred.

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