RN Care Transition Manager

The Integra RN Care Transition Manager supports the Transitions of Care team by conducting telephonic follow-up with patients transitioning out of acute care settings. Working collaboratively with physicians, continuing care coordinators, social workers, and patients, this role ensures appropriate community resources are in place and intervening when patients cannot be managed adequately. This is a temporary bridge assignment supporting Integras ability to meet critical payer contract requirements, NCQA timeliness benchmarks, and quality standards. The work is entirely phone-based.

• Conduct post-hospital and ED follow-up phone calls within required timeliness windows (including 48-hour TCM calls)

• Apply Case Management principles to the acute care inpatient population to ensure appropriate utilization of resources and level of care

• Facilitate discharge planning for Integra ACO patients in observation or admitted status, including referrals to skilled nursing, home health, outpatient providers, and infusion therapy

• Identify barriers to patient flow and collaborate with the interdisciplinary team to resolve them

• Identify patients requiring Case Management and Social Service referrals

• Complete all documentation accurately and timely in Epic and Cerner

• Act as a resource to the ED Hospital Liaison

• Support process improvement efforts focused on reducing unnecessary admissions, readmission rates, and improving flow metrics

• Maintain patient confidentiality in compliance with HIPAA at all times

Required Qualifications

• Active, unencumbered Registered Nurse (RN) licensure in Rhode Island

• Med/Surg RN background strongly preferred

• Minimum 5 years of related clinical experience in Acute Care or Case Management

• Knowledge of utilization review, discharge planning, and third-party payor regulations

• Strong interpersonal, oral, and written communication skills

• Demonstrated analytical ability, leadership, and effectiveness in team environments

Preferred Qualifications

• Experience in telephonic case management or Transitions of Care

• Familiarity with Epic and/or Cerner documentation systems

• Bachelors Degree in Nursing (BSN) or equivalent

• Previous care management experience (a plus, not required)