Care Manager - Care Transitions (RN)

Description

Your passion belongs at UNC Health. Join more than 56,000 teammates working together to improve the health and well-being of the communities we serve across North Carolina.

Summary:

The Care Manager - Care Transitions (Transitional Care Case Manager) supports high-risk patients following hospital discharge to promote safe transitions and reduce avoidable readmissions. Through telephonic assessment, education, medication review, care coordination, and connection to community resources, the TCCM provides transitional care support based on patient needs and program requirements. The role collaborates with patients, caregivers, and providers to support adherence to the care plan, ensure appropriate follow-up care, and improve outcomes. Beyond individual patient care, the TCCM tracks and analyzes readmission data and presents trends and findings to the care management team and interdisciplinary partners to inform broader efforts to reduce avoidable readmissions.

Responsibilities:

• Identifies high-risk admissions and prioritizes patients for transitional care follow-up based on readmission risk.
• Contacts patients following discharge to complete telephonic assessments, review medications and patient understanding of the medication regimen, provide education and support regarding the treatment plan, and address transition-of-care needs in accordance with established guidelines.
• Educates patients and caregivers on disease management, medication adherence, symptom recognition, and appropriate care resources; reviews discharge plans, facilitates follow-up care, and identifies barriers that may impact successful recovery and care transitions.
• Identifies gaps in care and coordinates referrals, community resources, and support services to address patient needs and promote successful care transitions.
• Monitors patient progress throughout the transitional care period through ongoing follow-up and maintains accurate documentation of patient interactions, interventions, and outcomes.
• Tracks and analyzes readmission data to identify patterns, trends, and contributing factors across the patient population.
• Maintains readmission tracking tools and reporting dashboards, ensuring data accuracy and timely updates.
• Conducts root-cause review of readmissions to identify avoidable factors and opportunities for intervention.
• Prepares and presents readmission data, outcomes, and trend analyses to case management leadership and interdisciplinary committees.
• Collaborates with the interdisciplinary care team, including case management, utilization review, and clinical partners, to translate readmission findings into actionable strategies that reduce avoidable readmissions.

PARDEE

Other information:

Required

• Must be licensed to practice as a Registered Nurse in the state of North Carolina or one of the compact states.
• Three (3) years of experience in a clinical capacity in an acute care, home health, or long-term care setting.
• One (1) year of experience working as a Registered Nurse (RN).
• Excellent verbal and written communication skills.
• Cultural competency and/or experience working with individuals from a wide range of backgrounds.
• Current Basic Life Support (BLS) certification.
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• Preferred
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• Bachelor's of Science in Nursing (BSN).
• Experience working in a Case Management/Discharge Planning capacity.
• Experience with community resources and agencies.
• Experience with data tracking, analysis, and reporting tools (e.g., spreadsheets and dashboards).

01.6015.1504

Legal Employer: Pardee - HCHC

Entity: Pardee UNC Health Care

Organization Unit: Acute Care Case Management

Work Type: Full Time

Standard Hours Per Week: 40.00

Work Assignment Type: Hybrid

Work Schedule: Day Job

Location of Job: PARDEEHOSP

Exempt From Overtime: Exempt: Yes

Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation.