Hospital Medicine Transition Manager (Nurse Case Manager

Come grow with us! Medrina has been voted one of the fastest growing companies and 92% of our employees feel we are a Great Place To Work! For more details on what our employees say go to Working at Medrina | Great Place To Work®.

We offer an annual salary of $85,000 with teleworker monthly stipend of $100. We offer a robust benefits package including 15 days of vacation, 7 paid holidays, and 5 sick days annually and group healthcare benefits, which begin day one and include health/dental/vision plans (multiple plans to choose from), employer-paid life insurance, tuition reimbursement, 401(k) with a company match and more.

This is a full-time hybrid position, working 3 days per week from the office and also traveling to our partner sites in the Palm Beach, FL area. While working from home, work must be performed in a private and quiet (with a door) setting requiring reliable internet and phone connectivity. Ability to communicate via virtual/online meetings with a camera on as well as being responsive in a timely manner during work hours via email, MS Teams and phone is required.

This is not a flex hours job. Candidates must reside in Palm Beach, FL, USA. This role does not offer immigration visa sponsorship.

• Collaborate daily with hospital case managers, social workers, physicians, and nursing teams to identify patients appropriate for post-acute care.
• Assist in coordinating timely discharges to skilled nursing facilities, rehabilitation centers, LTACHs, assisted living facilities, or home, as clinically appropriate.
• Identify and proactively address barriers that may delay discharge, including insurance authorization, facility acceptance, transportation, clinical documentation, and family concerns.
• Facilitate communication between the hospital care team and receiving post-acute providers to ensure a seamless transition of care.

• Work closely with Medrina hospital providers to identify discharge opportunities and support efficient patient throughput.
• Communicate patient status, anticipated discharge plans, and post-acute placement updates to providers.
• Coordinate with Medrina post-acute providers to ensure continuity of care following discharge.
• Assist providers in navigating post-acute placement options based on patient needs and preferred facility networks.

• Maintain strong working relationships with partner skilled nursing facilities and admissions teams.
• Coordinate referrals and facilitate acceptance of appropriate patients into participating facilities.
• Monitor bed availability and communicate placement options to hospital teams.
• Ensure clinical documentation and necessary information are transferred promptly to receiving facilities.

• Educate patients and families regarding post-acute care options and discharge expectations.
• Assist patients and caregivers in understanding the transition process and next steps.
• Address questions and coordinate communication among providers, facilities, and family members to support a positive patient experience.

• Support initiatives focused on reducing hospital length of stay and preventable readmissions.
• Monitor transition metrics and identify opportunities for process improvement.
• Participate in interdisciplinary rounds and discharge planning meetings.
• Escalate complex discharge issues to leadership when appropriate.
• Assist with implementation of value-based care initiatives and transitional care programs.

• Maintain accurate documentation of care coordination activities.
• Track referrals, patient transitions, discharge outcomes, and key performance indicators.
• Prepare reports for leadership related to discharge efficiency, placement success, and transition metrics.
• Ensure compliance with HIPAA, CMS regulations, and organizational policies.

• Registered Nurse (RN), Licensed Practical Nurse (LPN), Licensed Clinical Social Worker (LCSW), Social Worker (BSW/MSW), or healthcare professional with equivalent hospital case management experience.
• Minimum of 3 years of experience in hospital case management, discharge planning, utilization management, care coordination, or transitions of care.
• Strong knowledge of Medicare, Medicare Advantage, Medicaid, and commercial insurance authorization processes.
• Understanding of skilled nursing facility admission criteria and post-acute care resources.
• Excellent communication, relationship-building, and organizational skills.
• Ability to manage multiple priorities in a fast-paced hospital environment.

• Certified Case Manager (CCM) or Accredited Case Manager (ACM).
• Experience working with hospitalist groups or physician organizations.
• Knowledge of value-based care, ACOs, bundled payment programs, or population health.
• Experience with hospital electronic medical records (Epic, Cerner, Meditech, etc.).

We are an equal opportunity…