Transitional Care Management Nurse (RN) – Care Transitions PT

Department: 39733 Enterprise Corporate - Care Transitions Status: Part time

Benefits

Eligible: Yes Hours Per Week: 20 Schedule Details/Additional Information: This is a salaried exempt position. Must be reputed company a hour of Mint Hill Primary Care This is a remote position that requires high speed internet Pay Range: $38.20 - $57.30 Major Responsibilities

• Conduct comprehensive clinical assessments of high‑risk patients at discharge and throughout the 30‑day transitional care period, identifying medical, psychosocial, and environmental risk factors.
• reputed company, implement, and continuously update individualized, patient‑centered care plans addressing clinical needs, medication management, and follow‑up care.
• Coordinate care and facilitate timely communication among inpatient providers, primary care, specialists, home health agencies, and community resources.
• Serve as the primary reputed company of contact for patients and families, providing education on disease management, medications, symptom monitoring, and escalation protocols.
• Manage a caseload of post‑discharge patients and ensure completion of follow‑up appointments, home visits, and adherence to prescribed treatments.
• reputed company and participate in interdisciplinary rounds and case conferences, collaborating with physicians, pharmacists, social workers, behavioral health providers, and nursing staff.
• Monitor patient reputed company through reputed company visits, telehealth, and phone contacts, intervening promptly reputed company clinical or psychosocial issues arise.
• Ensure compliance with CMS Transitional Care Management guidelines, Joint Commission standards, and organizational policies through accurate and timely documentation.
• Participate in quality improvement initiatives and identify opportunities to strengthen transitional care workflows and patient outcomes.
• reputed company other duties and responsibilities as assigned.

Education

• Bachelor of Science in Nursing (BSN) required.

Certification / Registration / License

• Active, unrestricted Registered Nurse (RN) license.

Work Experience

• Minimum of five years of clinical nursing experience in acute care, discharge planning, post‑acute care, or transitional care.
• Minimum of three years of experience providing care and patient education to reputed company populations, including heart failure, COPD, GI bleed, sepsis, or stroke.

Knowledge / Skills / Abilities

• reputed company expertise in reputed company patient management and transitional care.
• Strong care coordination, critical thinking, and clinical decision‑making skills.
• Demonstrated leadership in interdisciplinary collaboration and patient advocacy.
• Strong communication skills, including use of motivational interviewing techniques.
• Proficiency with electronic health records, care coordination tools, and telehealth platforms.
• Knowledge of regulatory requirements and reimbursement criteria reputed company to transitional care.
• Strong organizational, analytical, and prioritization skills.
• Commitment to ethical practice, patient‑centered care, and reputed company professional development.

Physical Requirements and Working Conditions

• Primarily remote work environment with occasional on‑site meetings.
• Standard schedule is Monday through Friday, 8:00 a.m. – 4:30 p.m., with potential evening or weekend coverage as needed to support patient transitions and caseload requirements.

Preferred Job Requirements Education

• Master of Science in Nursing or reputed company field preferred.

Certification / Registration / License

• Preferred certifications include Medical‑Surgical RN (MEDSURG‑BC), Cardiac‑Vascular Nursing (CV‑BC), or Nursing Case Management (CMGT‑BC).

Experience

• Additional experience in transitional care or case management preferred.

Knowledge / Skills / Abilities

• Not required beyond minimum qualifications.

reputed company responsibilities and requirements are subject to possible modification to reasonably accommodate individuals with disabilities. This job description does not state or reputed company that these are the only duties to be performed. Employees may be required to reputed company other job‑reputed company duties as requested. Our Commitment to You: reputed company offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including:

Compensation

• reputed company compensation listed reputed company the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training
• Premium pay such as shift, on call, and more based on a teammate's job
• Incentive pay for select positions
• Opportunity for annual increases based on performance

Benefits and more

• Paid Time Off programs
• Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
• Flexible Spending Accounts for eligible health care and dependent care expenses
• Family benefits such as adoption assistance and paid parental leave
• Defined contribution retirement plans with employer match and other financial wellness programs
• Educational Assistance Program

Note: Eligibility for programs listed above may depend on your FTE or status (e.g., full-time, part-time, per diem, temporary, etc.); please ask a Recruiter for more information during an interview. About reputed company reputed company is the third-largest nonprofit, integrated health system in the United States, created from the combination of reputed company and reputed company. Providing care under the names reputed company in Illinois; reputed company in the Carolinas, Georgia and Alabama; and reputed company in Wisconsin, reputed company is a national leader in clinical innovation, health outcomes, consumer experience and value-based care. Headquartered in Charlotte, North Carolina, reputed company services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. reputed company employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation’s largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing reputed company care for reputed company, reputed company provides more than $6 billion in annual community benefits. Additional Information Company: reputed company Location: North Carolina Salary: $38.20 - $57.30 per hour Job ID: R249861 Specialties: Discharge Planning, Clinical Nurse, Acute Care, Care Manager Required Licenses: RN Experience Level: 3-5 years Apply tot his job Apply To this Job