Transitions of Care RN Case Manager

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Transitions of Care RN Case Manager based in United States. This remote role supports high-risk patients during the critical 30 days following hospital discharge.You will provide short-term, telephonic, interdisciplinary care management focused on preventing avoidable readmissions.The role combines clinical assessment, patient education, care coordination, and advocacy.You will build individualized care plans that address medical, psychosocial, medication, and resource-related needs.Working closely with nurses, physicians, social workers, primary care providers, and community resources, you will help patients navigate complex care journeys.The environment is collaborative, technology-enabled, and focused on measurable outcomes and exceptional patient experiences.This is an opportunity to make a direct difference for vulnerable patients while helping shape innovative approaches to healthcare delivery.