Job Description

Location: Steward Health Care
Posted Date: 7/13/2021


This position would focus on care coordinates and implements the function of transition planning for inpatient and outpatient services. Identifies and anticipates transitional care planning needs for each identified patient. Communicates and collaborates with the patient and post-acute primary providers through verbal and written communication. Responsible for the integration of the patient into the care of post-acute primary care using standards of transitional planning (developing, planning, implementing, and evaluating) in accordance with existing federal, state, and local standards. Adheres to confidentiality policies specific to communication, record keeping, and coordination of services. Responsible for documentation in all areas of transitional care. Transition Care Manager will provide assistance to patients, families, and/or significant others. Facilitates assistance when psychosocial factors impact the recovery process. The Transition Care Manager is responsible for applying medical necessity criteria to patients entering the hospital. Education is provided to physicians and other members of the team on the issues related to utilization review including inappropriate admissions and placements. Acts as patient advocate by negotiating for, and coordinating resources with payers, agencies and vendors for treat and release patients, as appropriate. This position is responsible for implementing specific readmission prevention activities in collaboration with the physician and hospital staff, such as collecting patient clinical and demographic data, educating the patient and family on disease management strategies, arranging for post- discharge support services. Transitional Care Manager seeks guidance from VP oof Care Management as needed


  • Initiates transitional care planning of patients in assigned age groups based on physicians order
  • Screen patients appropriately for transitional care planning and readmission avoidance tactics whenever possible.
  • Develops a clear list of interventions to support patient through transition to home and post acute service needs
  • Participates in reporting of suspected abuse or neglect of patient prior to hospitalization, as indicated by hospital policy, protocol.
  • Communicates with emergency department physicians and attending physician regarding post-discharge follow-up care provider.
  • Coordinates post-acute primary care provider appointment for identified patients with ACO- SHCN or referral to the call center or links to call in program established
  • Collaborates with Steward health care team members to develop post-acute follow-up patient care plan and document care plan in location that provider can access
  • Coordinates with Care Management in ensuring patient has resources for discharge medication needs.
  • Follows policies and procedures for the identification of medically related social and emotional needs of the patient and makes SW referrals for psychosocial determinants of life concerns.
  • Makes follow-up calls as appropriate to discuss discharge instruction questions, medication access, follow-up appointment schedule
  • Compiles and maintains a transitional care planning directory with community resources.
  • Develops a hand off cadence for when starting day and ending day
  • Communicates and collaborates with hospital staff and physicians for transitional care.
  • Identifies potential and/or actual barriers to transitional plan.
  • High Risk factors are to be used to identify patients with potential social service needs.
  • Transition Care nurse will make a referral to a inpatient Case Manger or social worker, per policy, when high risk factors are identified.
  • Participates on readmission improvement teams or committees, as directed.
  • Refers potential quality issues to leadership. This includes referrals to Risk Management, Pharmacy, or Infection Control.
  • Demonstrates skills and knowledge for age-specific factors and age-related competencies necessary for patients served: early adult, mid-adult, and late adult (geriatric). Allows patient to participate in decision-making and planning of care. Referrals made to social worker of any patient concerns of life style changes, interruption in employment, or separation from family. Takes into consideration any religious or cultural needs when discharge planning. Considers mobility needs and provides appropriate transportation.
  • Maintains current information on insurance requirements and community resources.


Experience in one or more areas (multiple experience preferred) of transitional care planning, discharge planning, social services, and/or care management. Demonstrates ability to interpret a variety of handwritten clinical data. Maintains attention to detail in a fast-paced work environment with minimal supervision. Maintains a pleasant, tactful manner when working with people in stressful situations. Is familiar with Medicare/Medicaid regulations and financial assistance. Is skillful in dealing with physicians to resolve transitional care issues. Possesses a working knowledge of community resources and services. Acts as a liaison between physicians, staff, patients, and families. The Transitional Care Manager assesses patients to identify psychosocial needs requiring intervention. It is recognized that there are variations in the approach utilized by different practitioners.


  • Education: Diploma or Associates RN or LPN with Case Management in acute or post-acute experience
  • Experience (Type & Length): 3 – 5 years’ experience in healthcare
  • Certification/Licensure: RN or LPN in state serving
  • Software/Hardware: Excel Word Meditech Allscripts
  • Other: Two (2) years’ experience as a Care Manager preferred . Experience in status management and transitional care preferred. Case Management Certification preferred. Must have working knowledge of MS office to include Word, Excel, Power Point.

Application Instructions

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