RN Case Manager

Job Description

RN Case Manager


Los Angeles, CA (Fully Remote)

The RN Case Manager - LTAC Transitions facilitates safe, timely, and well-coordinated transitions of patients from Long-Term Acute Care (LTAC) settings to lower-but medically appropriate-levels of care, including skilled nursing facilities, sub acute units, or home and community-based programs.

Working within a hybrid model, the Coordinator spends designated days on-site at partner LTACs to participate in care rounds, engage with discharge planners, and coordinate directly with facility teams, while performing administrative and follow-up tasks remotely on non-onsite days.

This position serves as the operational bridge between LTAC staff, Presidium providers, external facilities, and community partners-ensuring continuity, compliance, and strong communication across all transitions of care.


Compensation & Schedule


Compensation: $60,000 - $110,000 annually

Schedule: Full-time

Benefits: 3 weeks paid time off (2 weeks + 6-7 federal holidays), 401K, Medical, Dental, and Vision.

Onsite (LTAC-Facing) Responsibilities

• Participate in interdisciplinary rounds and discharge planning meetings on behalf of Presidium.
• Serve as the point of contact for LTAC case managers, social workers, and clinical staff regarding patients attributed to Presidium.
• Review provider discharge readiness decisions and ensure orders, documentation, and authorizations are initiated promptly.
• Identify barriers to discharge (e.g., authorization delays, placement availability) and escalate to the Director of Care Management or supervising provider.
• Support family and caregiver education on post-discharge instructions, follow-up appointments, and care continuity resources.

Remote (Administrative & Follow-Up) Responsibilities

• Complete discharge documentation, coordination notes, and communication logs in the EHR or designated coordination platform.
• Arrange logistics including transportation, DME, pharmacy coordination, home health orders, and post-discharge appointments.
• Communicate with SNFs, home health agencies, and community partners to ensure readiness to receive the patient.
• Confirm successful transfers and monitor members for 30-day readmission or escalation risk.
• Conduct post-transition outreach calls to verify continuity and patient satisfaction.
• Coordinate with internal ECM and Community Supports teams for warm handoffs into ongoing wraparound programs.

Cross-Functional Collaboration

• Collaborate closely with Presidium providers and interdisciplinary teams to align discharge plans with the patient's clinical needs and social circumstances.
• Communicate proactively with health plans or managed care organizations to confirm authorizations or clarify next-level placement requirements.
• Participate in internal quality-improvement initiatives focused on readmission prevention and transition efficiency.
• Maintain compliance with HIPAA, CMIA, and all internal privacy and data security policies.

Documentation and Reporting

• Ensure all transition and coordination notes are entered within 24 hours of activity.
• Track and report transition status metrics (timeliness, barriers, outcomes) through dashboards or assigned templates.
• Support monthly performance review meetings by providing updates on active transitions, resolved barriers, and quality indicators.

Education & Licensure Requirements

• Preferred: Registered Nurse (RN) or equivalent clinical training.
• Minimum: Associate degree in Nursing, Health Sciences, Social Services, or related field; or equivalent combination of education and healthcare coordination experience.
• Desirable: Bachelor's degree (BSN, BA/BS in Health Administration, Public Health, or Social Work).
• Valid California driver's license and reliable transportation (for travel to partner LTAC facilities).

Experience Requirements

• Minimum 3 years' experience in care coordination, discharge planning, or case management within LTAC, acute hospital, SNF, or managed-care environment.
• Experience coordinating services and authorizations with health plans, providers, and community partners.
• Familiarity with CalAIM, ECM, or Community Supports preferred.
• Strong interpersonal skills with the ability to communicate effectively across clinical and administrative teams.
• Highly organized with the ability to manage multiple transitions and shifting priorities in a fast-paced environment.

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