Bachelor's Degree in Nursing preferred, or 5 years in healthcare organizations.
2 years experience in transitional care, nurse navigation, or case management preferred.
Knowledge of CMS regulations and accreditation standards preferred.
Certified Case Manager (preferred) or willingness to acquire certification within 3 years.
Responsibilities
Conduct daily screenings of patients to assess readmission risks for transitional care.
Provide comprehensive discharge teaching including disease management, self-care, and medication education using the teach-back method.
Coordinate monthly case conferences with Community Hospital and Rocky Mountain Health Plans to ensure smooth patient transitions.
Educate patients about the Med-to-Bed program and connect them with outpatient pharmacists as necessary.
Schedule follow-up appointments with primary care providers before patient discharge or assist in finding a provider.
Make follow-up calls to discharged patients within 72 hours to check on their progress.
Ensure timely submission of discharge summaries to post-acute providers.
Benefits
Medical, dental, and vision insurance
Life Insurance
Free parking
Paid time off
Education assistance
403(b) with employer matching
Wellness program
Additional benefits based on employment status
Full Job Description
Position Highlights:
Job Type: Transitional Care Nurse (Case Manager)
Location: Community Hospital
Schedule: Full-Time
Application Deadline: Open until July 6, 2026
Responsibilities:
Daily inpatient screening and assessment of readmission risk factors to determine appropriateness for transitional care.
Discharge teaching, including disease teaching, self-care, lifestyle changes, needed medical equipment (such as oxygen, incentive spirometry) and medication reconciliation/education. Uses teach back method to ensure patient and family understanding. Involves family members with discharge teaching.
Coordinates the monthly case conference between Community Hospital and Rocky Mountain Health Plans, gathering patients and collaborating with Rocky for patient transitions.
Educates patient regarding Med-to-Bed program, facilitating that connection between patient and outpatient pharmacist, if needed.
Schedules primary care provider (PCP) appointment for patient before discharge. If the patient has no PCP, the TCRN works with case management to arrange follow-up, or helps patient to fill out application for PCP.
Follow-up phone call to patients within 72 hours of discharge.
Ensures discharge summary is sent to post-acute provider within 24 hours of discharge (or as soon as available).
In the future, may be required to perform non-skilled home visits to patients who have been determined to be readmission risks, up to 2 times, to assess learning and physical needs, as well as to arrange further care if needed.
Requirements:
Bachelor's Degree in Nursing Preferred, and/or 5 years of healthcare organization experience. Two years of experience in transitional care, nurse navigation, or Case Management preferred.
Current working knowledge of Rules/Regulations CMS (CoPs), ORYX Core Measures, and accreditation bodies (TJC/DNV) preferred.
Certified Case Manager (preferred) or willing to obtain within 3 years of employment.
Compensation:
$39.00 - $44.85 per hour, depending on education and experience.
Bonus: $5,000
Discretionary bonuses, relocation expenses, merit increase, market adjustments, recognition bonuses, and other forms of discretionary compensation may be available.
Benefits:
Medical, dental, vision insurance
Life Insurance
Free Parking
Paid time off
Education assistance
403(b) with employer matching
Wellness Program
Additional benefits based on employment status
Additional Information:
Relocation: Must relocate to Grand Junction, CO 81505 before starting work.
