Case Management Nurse

Company-Provided Equipment

We are seeking a fully bilingual English/Spanish RN Case Manager to support high-risk patients through chronic care management, transitions of care, and coordinated care planning.

This is a direct-hire, hybrid opportunity based in Tucson. The selected RN will typically work 2–3 days per week onsite at the center, with the remaining days working remotely
. Specific onsite days are still being finalized.

The ideal candidate will have experience in case management, transitions of care, discharge planning, chronic care management, utilization management, or managed care
, along with strong knowledge of post-acute care resources.

• Oversee chronic care management and transitions of care for high-risk patients
• Serve as a clinical resource to multidisciplinary teams managing complex patients
• Complete comprehensive assessments addressing physical, mental, and social risk factors
• Develop and coordinate individualized care plans based on patient needs and identified barriers
• Perform telephone triage and appropriately address or elevate patient concerns
• Coordinate patient transitions from acute and post-acute settings to home or other transitional care facilities
• Collaborate with physicians, nursing staff, ancillary providers, and other members of the care team to remove barriers to appropriate care
• Coordinate patient care progression across the healthcare continuum
• Monitor patient progress and intervene as needed to ensure care plans remain patient-centered, high-quality, efficient, and cost-effective
• Coordinate diagnostic testing, treatment plans, discharge plans, and modifications to the plan of care
• Ensure patients and families understand discharge instructions, care plans, and follow-up needs
• Coordinate post-discharge services including home health, hospice, DME, medications, and other medical supplies
• Schedule patients for PCP or specialist follow-up within 7 days of discharge
• Reconcile discharge medications and collaborate with PCPs and clinical pharmacists for medication review
• Review patients for eligibility for home health and other transitional care services
• Obtain medical records from acute care facilities, including orders, referrals, diagnostic results, and care team documentation
• Track and monitor hospital readmissions and participate in initiatives designed to reduce avoidable readmissions and hospitalizations
• Identify at-risk populations using approved screening tools and follow established reporting procedures
• Coordinate with external case managers and community providers
• Refer appropriate patients for social work intervention
• Use clinical, financial, and patient-satisfaction data to identify opportunities for performance improvement
• Participate in clinical performance improvement initiatives and readmission reduction programs
• Document assessments, patient calls, and care coordination activities accurately and timely in the EMR
• Utilize conflict-resolution and problem-solving skills to address barriers to care
• Maintain knowledge of the Four Elements of the Coleman Model and apply transition-of-care principles

• Bachelor’s degree in Nursing (BSN)
• Fully bilingual in English and Spanish — REQUIRED
• Candidates must be able to communicate professionally and effectively in both English and Spanish
• Conversational Spanish alone does not meet the requirement
• Minimum 2 years of Registered Nurse experience
• Minimum 2 years of experience in one or more of the following:
• Case Management
• Chronic Care Management
• Transitions of Care
• Cost/Quality Management
• Managed Care or related clinical programs
• Working knowledge of chronic care management, discharge planning, utilization management, case management, and/or managed care reimbursement
• Knowledge of pre-acute and post-acute care settings and community resources
• Strong communication, organization, clinical assessment, and care coordination skills

• Experience with Medicare Advantage
• Experience in Value-Based Care
• Managed Care experience
• Experience working with high-risk or medically complex patient populations
• Experience with transitions-of-care and readmission reduction programs
• Experience coordinating home health, hospice, DME, and community-based services

Monday–Friday | 8:00 AM–5:00 PM

• Typically 2–3 days per week onsite at the Tucson center
• Remaining workdays are remote
• Specific required onsite days are currently being finalized