Registered Nurse Case Manager - Transitions of Care

About the Role

A clinically experienced registered nurse responsible for leading care coordination for patients with complex and chronic medical conditions during critical transitions between care settings. This role combines advanced clinical judgment, interdisciplinary collaboration, and population health strategies to reduce readmissions, improve outcomes, and address social determinants of health. The RN Case Manager serves as the clinical lead for a multidisciplinary case management team, including community health workers, ensuring continuity of care across inpatient, outpatient, and community environments. This is an onsite position; only candidates who live or will live in the Austin area will be considered.

Responsibilities

• Perform thorough in-person and telephonic assessments, including home visits and clinic accompaniments, to evaluate medical, behavioral health, and functional needs, including social determinants of health (SDOH) and trauma-informed care considerations.
• Perform clinical assessments and interventions during patient crises (e.g., homelessness, substance use, psychiatric episodes). Coordinate emergency services, de-escalate situations, and connect patients with appropriate resources to ensure safety and continuity of care.
• Develop and manage individualized, culturally sensitive, and evidence-based care plans with measurable goals tailored to complex patient needs.
• Coordinate care across medical, behavioral, and social service providers to ensure continuity, reduce fragmentation, and support optimal health outcomes.
• Apply clinical experience and knowledge of high-risk populations to proactively manage complex cases and reduce disparities.
• Lead the case management team, serving as the clinical lead and supporting community health workers and others in outreach, engagement, and addressing social needs.
• Coordinate care across interdisciplinary teams including physicians, advanced practice providers, specialists, social workers, and community health workers.
• Facilitate timely establishment of primary care, dental, and specialty services for patients with complex medical needs, especially when access is delayed.
• Provide disease-specific education, medication education, and conduct medication reviews to promote safe and effective therapy use.
• Oversee medication management for PCP-prescribed medications, ensuring adherence, reconciliation, and access support.
• Educate and empower patients to access appropriate levels of care, including urgent care and outpatient services, to prevent avoidable emergency room visits.
• Utilize population health strategies such as preventive care and chronic disease management to improve patient outcomes.
• Engage patients and families in shared decision-making, self-management education, and culturally responsive care planning.
• Navigate and coordinate community-based services to address social determinants of health, including housing, food insecurity, transportation, financial barriers, and behavioral health access.
• Advocate for patients in navigating complex systems (Medicaid, disability, housing, legal aid) and overcoming systemic barriers.
• Enhance the patient experience by practicing AIDET during each patient interaction. Ensure culturally and linguistically appropriate communication with patients.
• Leverage EHR and population health tools to track outcomes, identify trends, and contribute to quality improvement initiatives.
• Serve as a preceptor for new clinical team members and students.
• Participate and lead continuous quality improvement projects to better serve patients, families, and the healthcare system.
• Attend staff meetings and education offerings in person and via teleconference/online as required.
• Plan and coordinate care daily with all members of the care team to assure maximum quality and efficiency of care.
• Support organizational initiatives to promote and maintain a strong positive workplace culture.
• Adhere to state board of nursing and state nurse practice act requirements and other governing agency regulations.
• Must have regular access to a vehicle to travel to and from patient locations.
• Perform other duties as assigned.

Requirements

• Graduation from an accredited School of Nursing with an Associate Degree in Nursing (ADN).
• Current unrestricted RN license to practice nursing in the State of Texas.
• Basic Life Support (BLS) certification obtained through an approved American Heart Association Training Network.
• Valid Driver’s License upon hire.
• 3 years of clinical nursing experience in a hospital, home health, or ambulatory clinic setting.
• 2 years of case management experience as it relates to the responsibilities of the position.
• 1 year of experience managing populations with complex medical needs.

Preferred Qualifications

• Case Management Certification (CCM).
• Accredited Case Manager Certification (ACM).

Skills

• High knowledge of complex medical conditions and comorbidities.
• Ability to thrive in a complex and dynamic work environment with multidisciplinary, cross-functional teams and matrixed team structures.
• Strong assessment, critical thinking, and effective decision-making skills.
• Knowledge of social determinants of health issues and sensitivity to underserved populations.
• Familiarity with evidence-based strategies to ensure safe and effective transitions between inpatient, outpatient, and community settings.
• Strong communication skills to support shared decision-making and self-management education.
• Strong patient advocacy skills, especially for vulnerable and underserved populations.
• High-level skill at fostering and maintaining relationships within the organization and with community partners.
• Strong attention to detail and accuracy.
• Experience with electronic medical records and healthcare-derived data.
• Ability to collaborate with patients, families, and care teams across the healthcare continuum.
• Exhibit compassion, vulnerability, and empathy.
• Provide patient-centered care that is inclusive and focuses on cultural humility.