Hospital Medicine Transition Manager
$960,000–$960,000 year
HybridWest Palm Beach, Florida, United States
Job Summary
Collaborate daily with hospital case managers, social workers, physicians, and nursing teams to identify patients appropriate for post-acute care and coordinate timely discharges to skilled nursing facilities, rehabilitation centers, or home. Facilitate communication between the hospital care team and receiving providers to ensure seamless transitions while educating patients and families regarding post-acute options. Maintain strong relationships with partner skilled nursing facilities to monitor bed availability and coordinate referrals, ensuring clinical documentation is transferred promptly. Support initiatives focused on reducing hospital length of stay and preventable readmissions by participating in interdisciplinary rounds and monitoring transition metrics. Prepare reports for leadership related to discharge efficiency and placement success while ensuring compliance with HIPAA and CMS regulations. This full-time hybrid role requires residing in Palm Beach, FL, and includes travel to partner sites.
Required Qualifications
- 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
- 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
- Candidates must reside in Palm Beach, FL, USA
- This role does not offer immigration visa sponsorship
Desired Qualifications
- 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.)
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