Registered Nurse - Complex & Transitional Care Manager Innovation Care Partners

Primary City/State:
Innovation Care Partners – 8901 E Mountain View Rd, Scottsdale, AZ 85258

Category:
Case Management
• Shift: Day
• Department:
Care Management

The Complex and Transitional Care Manager is responsible for managing the care of high-risk, medically complex patients throughout the continuum of care. This includes both chronic condition management and transitional support during care transitions (e.g., hospital discharge, rehab, home care). The goal is to improve clinical outcomes, reduce avoidable readmissions, and support safe, patient-centered care.

• Coordinate patient transitions between hospitals, skilled nursing facilities (SNFs), home health, primary care, and specialists.
• Conduct timely patient post‑discharge follow‑ups via telephonic calls or in‑home visits, as warranted.
• Facilitate patient/caregiver education at transitions of care and chronic care management.
• Develop and implement individualized care plans and transition plans in collaboration with patient/caregiver, PCP and embedded Care Coordinators.
• Monitor progress toward goals, adjust care plans as needed, and advocate for access to appropriate services.
• Document assessments, care plans, and interventions in the electronic medical record (EMR) accurately and in a timely manner.
• Collaborate with the Chief Medical Officer, providers, primary care, embedded Care Coordinators and other health care professionals/agencies to ensure complex outpatient care is coordinated across the health care continuum.
• Participate in quality improvement initiatives related to care transitions, chronic disease management, and utilization reduction.
• Maintain all regulatory educational requirements by participating in continuing education activities.
• Demonstrate professional behavior and promote cooperation and team building.
• Maintain and manage to their caseload.
• Support and participate in the development and maintenance of scorecard.
• Maintain accurate metric tracking for daily productivity management.
• Perform other duties or responsibilities as assigned by people leader to meet business needs.

• Associates Nursing – Required
• Bachelors Nursing – Required

• License Registered Nurse – New grad Required
• 1 year as Case (or Care) Manager, Transitional Care Manager, Care Coordinator RN or Nurse Advocate Required
• 2 years Registered Nurse – Preferred

• Registered Nurse (RN) – License State and/or Compact State Licensure – Required
• Basic Life Support (BLS) – Certification – Required
• Fingerprint Clearance Card (FPC) – Certificate – Required
• Certified Case Manager – Certification – Preferred
• Accredited Case Manager (ACM) – Certification – Preferred