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Care Manager, Transition of Care

Open Position: Care Manager, Transition of Care
Location: Memphis, TN
Type: Full-time

Care Manager, Transition of Care:
Are you in search of a dynamic work environment where you can learn and grow your career opportunities? Join the team at HealthChoice to collaborate with passionate health care professionals and help impact the lives of patients who have recently been discharged from the hospital and/or emergency room.

HealthChoice is seeking a full-time Care Manager for its Care Transition Support Program. The Care Manager is responsible for ensuring continuity of care for patients transitioning from the acute care setting to the home and community. The Care Manager ensures the patient has the most successful outcome and recovery experience possible.

Job Responsibilities:

  • Collaborates with care team members to facilitate care transitions within the post acute continuum.
  • Monitors hospitalizations and institutional facility admissions, re-admissions and ED utilization through daily review of patient census and reports, to identify discharge needs in anticipation of patient outreach and education to ensure transition to the home, the provider and community as indicated.
  • Conducts telephonic outreach to assess patient’s needs, educate on condition, medications and discharge instructions and formulate a care plan to ensure post-acute transitions.
  • Serves as a health coach, educator, and facilitator to ensure the patient’ understanding of their discharge instructions, medications, condition and use of available and appropriate services for their care.
  • Acts as an advocate for an individual's care needs by identifying and communicating opportunities for care interventions, including identifying and addressing functional deficits and gaps in care.
  • Coordinates service delivery; establishes treatment goals with the interdisciplinary team to meet the client’s individual healthcare needs reflecting the impact of patient’s educational, financial, religious, and cultural background.
  • Provides community referrals and resources to patients needing additional support.
  • Provides notification of discharge and other records as available to the patient’s providers.
  • Identifies high risk members for complex case management or chronic disease management programs.
  • Participates in patient care huddles to communicate patient care needs to the care team.
  • Reports quantifiable impact, quality of care and/or quality of life improvements as measured against the care coordination goals.
  • Establish and maintain professional working relations with referral sources, community resources and care providers.
  • Assists team in the development and modification of Care Management Programs.
  • Assists in the promotion of the Care Management Programs to providers, patients and other customers.


  • Bachelor’s degree in nursing
  • Current, unrestricted RN license in the State of TN or the ability to obtain prior to employment, or compact license agreement in place
  • 2+ years of experience in a hospital or acute care with direct care experience
  • 2 + years Case Management experience
  • Case Management Certification, ACM or CCM; or successfully completes board certification within 2 years of hire
  • Strong written and verbal communication skills with the ability to work with members, their families, and physicians in a tactful and professional manner
  • Proficient in Microsoft Word, Excel, Power Point

Additional Assets Preferred:

  • Experience in managed care, discharge planning, care coordination.
  • 1+ years of home care experience or specialty clinic experience.
  • Experience working with multidisciplinary teams preferred. 

Please send your inquiry with your resume and references attached to Sarah.Henning@myhealthchoice.com