Hospital Medicine Transition Manager (Nurse Case Manager)

We offer an annual salary of $85,000 with teleworker monthly stipend of $100. We offer a robust benefits package including 15 days of vacation, 7 paid holidays, and 5 sick days annually and group healthcare benefits, which begin day one and include health/dental/vision plans (multiple plans to choose from), employer-paid life insurance, tuition reimbursement, 401(k) with a company match and more. This is a full-time hybrid position, working 3 days per week from the office and also traveling to our partner sites in the Palm Beach, FL area. Candidates must reside in Palm Beach, FL, USA. While working from home, work must be performed in a private and quiet (with a door) setting requiring reliable internet and phone connectivity. Ability to communicate via virtual/online meetings with a camera on as well as being responsive in a timely manner during work hours via email, MS Teams and phone is required. This is not a flex hours job. This role does not offer immigration visa sponsorship. Job Responsibilities: Hospital Discharge Coordination: • Collaborate daily with hospital case managers, social workers, physicians, and nursing teams to identify patients appropriate for post-acute care. • Assist in coordinating timely discharges to skilled nursing facilities, rehabilitation centers, LTACHs, assisted living facilities, or home, as clinically appropriate. • Identify and proactively address barriers that may delay discharge, including insurance authorization, facility acceptance, transportation, clinical documentation, and family concerns. • Facilitate communication between the hospital care team and receiving post-acute providers to ensure a seamless transition of care. Provider & Clinical Support: • Work closely with Medrina hospital providers to identify discharge opportunities and support efficient patient throughput. • Communicate patient status, anticipated discharge plans, and post-acute placement updates to providers. • Coordinate with Medrina post-acute providers to ensure continuity of care following discharge. • Assist providers in navigating post-acute placement options based on patient needs and preferred facility networks. Skilled Nursing Facility Coordination: • Maintain strong working relationships with partner skilled nursing facilities and admissions teams. • Coordinate referrals and facilitate acceptance of appropriate patients into participating facilities. • Monitor bed availability and communicate placement options to hospital teams. • Ensure clinical documentation and necessary information are transferred promptly to receiving facilities. Patient & Family Engagement: • Educate patients and families regarding post-acute care options and discharge expectations. • Assist patients and caregivers in understanding the transition process and next steps. • Address questions and coordinate communication among providers, facilities, and family members to support a positive patient experience. Care Transition & Quality Improvement: • Support initiatives focused on reducing hospital length of stay and preventable readmissions. • Monitor transition metrics and identify opportunities for process improvement. • Participate in interdisciplinary rounds and discharge planning meetings. • Escalate complex discharge issues to leadership when appropriate. • Assist with implementation of value-based care initiatives and transitional care programs. Documentation & Reporting: • Maintain accurate documentation of care coordination activities. • Track referrals, patient transitions, discharge outcomes, and key performance indicators. • Prepare reports for leadership related to discharge efficiency, placement success, and transition metrics. • Ensure compliance with HIPAA, CMS regulations, and organizational policies. Job Requirement: • Registered Nurse (RN), Licensed Practical Nurse (LPN), Licensed Clinical Social Worker (LCSW), Social Worker (BSW/MSW), or healthcare professional with equivalent hospital case management experience. • Minimum of 3 years of experience in hospital case management, discharge planning, utilization management, care coordination, or transitions of care. • Strong knowledge of Medicare, Medicare Advantage, Medicaid, and commercial insurance authorization processes. • Understanding of skilled nursing facility admission criteria and post-acute care resources. • Excellent communication, relationship-building, and organizational skills. • Ability to manage multiple priorities in a fast-paced hospital environment. Preferred • Certified Case Manager (CCM) or Accredited Case Manager (ACM). • Experience working with hospitalist groups or physician organizations. • Knowledge of value-based care, ACOs, bundled payment programs, or population health. • Experience with hospital electronic medical records (Epic, Cerner, Meditech, etc.).