Job Description

  • Job LocationUS-AZ-SCOTTSDALE
    Requisition ID
    01 - Days
    Care Management
    Innovation Care Partners
    Position Type
    Regular Full-Time
    Physical Work Location and New Employee Orientation Location : Address
    Work Hours
    8:00 - 4:30
  • Overview

    HonorHealth is a non-profit, local healthcare organization known for community service and outstanding medical quality. HonorHealth encompasses five acute care hospitals with approximately 11,500 employees and 4,500 volunteers, over 70 primary and specialty care practices, clinical research, medical education, an inpatient rehabilitation hospital, an Accountable Care Organization, two foundations, and extensive community services.

    HonorHealth is a leader in medical innovation, talent and technology with a genuine commitment to your growth. The health system's vibrant careers take place in an environment filled with opportunity and respect because we see the HONOR in you.


    Associate's Degree from an accredited NLN /CCNE institution in nursing Required

    Two (2) years Registered Nurse (RN) Required
    One (1) year as Case (or Care) Manager Required

    Licenses and Certifications
    Registered Nurse (RN) State And/Or Compact State Licensure Required
    Basic Life Support (BLS) Required


    Job Summary
    The Transitional Care Manager RN is an integral member of the care management team, working with patients and their families to assure a smooth transition following discharge from the hospital. This position works collaboratively with the Chief Medical Officer, providers, hospital based specialists, Care Coordinators and other health care professionals/agencies to ensure a smooth transition from the hospital to outpatient care that is coordinated across the health care continuum.
    • The Transitional Care Manager RN collaborates with patients/caregivers early in the inpatient episode in preparation for discharge. Key areas of focus include:
      •Establish relationship with patient/caregiver
      •Assure PCP is aware of patient’s admission
      •Assess readmission risk and barriers to care outpatient including home support, medication management, expectation, etc.
      •Coordinate with hospital case manager regarding discharge plans
      •Monitors and reviews cases that are in the emergency room; facilitate the notification of network providers if patients utilize the ER. Participate and support the ED Staff with the patients most appropriate setting for care.
      •Provide effective communication of clinical information and plan of care between the Hospitalist, Emergency Room Physician, Specialists, and PCP; as well as other key healthcare providers involved in the case.
      •Conduct effective post-hospitalization telephonic monitoring, or depending on the tier level of each case and risk for readmission.
      •Review discharge instructions with patient including education required due to new medications/changes to medication regimen, disease specific "red flags" of complications
    • The Transitional Care Manager will facilitate a smooth and timely transition from acute care back to the appropriate primary care office.
      •Coordinates follow-up care with PCP and practice Care Manager /health coach(office based or centralized) regarding outpatient follow-up appointment and plan of care
      •Communicates key information regarding inpatient stay and discharge plans to patient’s PCP/office care manager/health coach.
      •Assures effective transition and final hand-off to the patient’s PCP and his/her office based care manager/health coach.
      •Coordinate with (employee plan) or Payer Care Management regarding support desired/required.
    • Facilitates and promotes a collaborative process and communication between all health care team members, inclusive patients/clients, families and significant others to ensure the process of integrated care services are targeted, appropriate, and beneficial to the population served from admission through the discharge process.
    • Communicate effectively and professionally using all modalities i.e. technology, written letter, and verbal with both clinicians and patients/caregivers in a way that is both clear and concise. Assesses, determines, and evaluates appropriate disposition and makes independent judgments based on critical thinking skills and expertise.
    • Performs active listening, uses motivation interviewing and open ended questioning techniques and guided care goal setting for the patient.
    • Maintains all regulatory educational requirements participating in continuing education and quality improvement activities. Demonstrates professional behavior and promotes cooperation and team building
    • Demonstrates technical skill and new forms of technology in maintaining clear and professional clinical documentation in software data base for cases followed under transition and for case assignment.
    • Supports and participates in the development and maintenance of Scorecard. Maintains accurate metric tracking for daily productivity management.
    • Maintains and manages to their caseload
    • Performs other duties as assigned

    It is the policy of HonorHealth to provide equal opportunity in employment. Selection and employment of applicants will be made on the basis of their qualifications without regard to race, color, religion, creed, national origin, age, disability, sexual orientation, marital status, veteran status or any other legally protected status.

    Please review the Equal Employment Opportunity poster.

    Please review the Equal Employment Opportunity Poster.HonorHealth wants all interested and qualified candidates to apply for employment opportunities. If you are an applicant with a disability who is unable to use our online tools to search and apply for jobs, please contact us at . Please indicate the specifics of the assistance needed. This option is reserved only for individuals with disabilities that are unable to use the online tools and is not intended for other purposes.

    Application Instructions

    Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!

    Apply Online