RN Case Manager, Transitional Care
Melville, NY
Prime Staffing
5x8 hrs

ID: 63548700 Shift: Day 5x8-Hour (08:00 - 16:00) Description: Hours: 8-4pm. Occasional weekends.The position will support a new program that the Quality Department is putting in placeGeneral Summary: The Transitional Care Management (TCM) Registered Nurse (RN) is responsible for coordinating and managing patient care transitions following discharge from an inpatient facility, emergency department, skilled nursing facility, or other care settings. The TCM RN works collaboratively with providers, practice staff, patients, caregivers, and community resources to reduce readmissions, improve patient outcomes, support quality performance measures, and ensure timely follow-up care in alignment with value-based care initiatives.The TCM RN utilizes evidence-based practices, population health strategies, and High Reliability Organization (HRO) principles to ensure safe, efficient, and patient-centeredDuties/Responsibilities:Transitional Care Management Conduct outreach to discharged patients within required timeframes (typically within 48 business hours of discharge). Complete comprehensive post-discharge assessments including: oMedication reconciliation oReview of discharge instructions oIdentification of barriers to care oEvaluation of symptoms and clinical concerns Coordinate and schedule timely follow-up appointments with Primary Care Providers (PCP) and specialists. Ensure completion of TCM documentation requirements in EPIC. Monitor high-risk patients for complications, worsening symptoms, or readmission risk. Escalate clinical concerns to providers promptly using appropriate communication tools (SBAR). oAssessment of social determinants of health Care Coordination Collaborate with physicians, advanced practice providers, nurses, social workers, care managers, and hospital liaison to ensure continuity of care. Facilitate referrals for home care, behavioral health, palliative care, pharmacy support, or community resources as needed. Assist patients and caregivers in understanding diagnoses, medications, treatment plans, and self-management strategies. Modified Time:6/29/2026 5:00:00 AM Account Manager: Chris Stearns Account Manager Email: COVID-19 Vaccine: Required - Medical Exemptions Only Flu Vaccine: Unknown Submittals:High Job Requirements & Qualifications Previous Charge Experience : - Years of Experience : Patient Ratio Experience : Charting System Experience : - Charting System Name : Community Hospital Experience : - LTAC Experience : - Trauma Level I Experience : - Trauma Level II Experience : - Travel Experience Required : - Certifications : Skills : Unit Details Staffing & Scheduling Scheduling Type : - Patient Ratios Days : - Patient Ratios Nights : - Patient Ratios Weekends : - Float Required : - Call Required : - Weekend Coverage : - Number of Weekend Shifts Per Contract : - Pre-Approved Time Off : - Orientation Hours : - Facility & Patient Care Details Patient Age Groups : - Daily Census : - Number of Visits Per Day : - Number of Rooms : - Number of Beds : - Additional Unit Information Interdisciplinary Support : - Patient Diagnoses : - Special Procedures/Unit Details : - Special Equipment : Guaranteed Hours: Contract Weeks:91