RN Care Manager - Hospital Transition of Care Liaison

Overall Purpose

Are you a compassionate mission-driven nurse looking to make a meaningful impact on the lives of complex medical patients? As a nurse care manager at P3 Health Partners, you’ll bring hope and healing to patients with complex medical needs. In this full-time role, you’ll be a vital member of an interdisciplinary team, transforming lives and empowering primary care physicians to deliver exceptional care to those who need it most.

The scope of practice includes, but is not limited to, ensuring assigned hospital patient population(s) receive continuous, comprehensive, and coordinated care throughout the continuum. Through case finding, data and other tools, patients will be identified and guided to enhance the achievement of the Quadruple Aim: improved outcomes, improved experience of care for patients and providers and lower healthcare costs.

The Hospital-Based Transition of Care Liaison (RN Care Manager) will utilize nursing assessment, planning, implementation, and evaluation, as well as clinical judgment. Interventions with patients and/or stakeholders may be face-to-face or telephonic. The RN Hospital-Based Care Manager may be responsible for activities overlapping with utilization review and quality management programs. You will cover the hospital(s) for which you are hired.

• Responsible for comprehensive patient assessments through medical records, clinician input, and interviews with patients, caregivers, and hospital staff.
• Maintain close follow-up with all patients, amending care plans as necessary at each contact.
• Educate patients, families, and caregivers about care plans.
• Support advanced care planning, including palliative and hospice care when appropriate.
• Communicate with the comprehensive care team, hospital care team, and primary care physicians regarding individualized care plans and patient progress.
• Identify patient care needs and barriers to care.
• Apply strong clinical judgment and problem-solving skills.
• Develop and implement plans to mitigate barriers to patient self-management.
• Prepare documentation according to P3 Health Partners workflows and policy.
• Promote self-management and enable patients to meet care plan goals.
• Build relationships with PCPs, internal and external customers.
• Communicate opportunities to advance clinical models.
• Use associated technology and computers confidently.
• Ensure patient privacy and adhere to all HIPAA regulations regarding PHI.
• Participate in flexible staffing when capacity requires.
• Participate in quality improvement initiatives, documentation audits, and other activities that support clinical excellence and operational efficiency.
• Maintain compliance with required training, chart closure timelines, meeting attendance, and other obligations.
• Serve as a positive and collaborative team member, role modeling P3 Health Partners core values.
• Engage in other patient care projects as assigned.

• Active and unencumbered nurse in the state of practice.
• Active case management certification.
• Minimum one year of case management experience, preferably geriatric medicine.
• Strong clinical judgment, problem-solving, and critical thinking skills.
• Excellent communication skills with patients, providers, and external customers.
• Excellent computer skills.
• Excellent organizational skills and ability to work independently with minimal supervision.
• Flexible, self-driven, and innovative personality.

• Minimum two years of clinical nursing experience in care management or with a managed care/HMO organization.
• Discharge planning experience preferred.
• Understanding of utilization management preferred.
• Understanding of HEDIS measures preferred.

• Graduate from an accredited school of nursing.
• Bachelor’s degree in nursing preferred.

• Ability to obtain and maintain current Registered Nurse license in the state(s) where P3 Health Partners operates.
• Certification in Case Management (CCM or ACM) within one year of hire.

• Travel between counties where P3 Health Partners is located in the state of hire is required.

Pay Range: $85K-95K

P3 Health Partners is a population health management group founded and led by physicians who want to shift the industry’s focus from managing illness to cultivating wellness. We are health‑plan agnostic and work with most plans in our markets. As the conduit between you and the health plan, we want to make a difference where it counts - with your patients, their families, and the communities where we live.

The mission of P3 is simple: we want to help providers and their patients embrace a new kind of care—a kind of care that gives patients the tools and resources they need to manage their long‑term health and wellness.

Our core values guide us:

• People – Our commitment to compassionate care.
• Passion – Our drive to innovate and improve health outcomes.
• Purpose – Our focus on meaningful impact.