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Care Transitions Nurse | PCG Job

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Date: Jun 24, 2022

Location: Memphis, TN, US

Company: Methodist Le Bonheur Healthcare


The Care Transitions Nurse is responsible for coordination of care and service delivery for an assigned group of patients.  Promotes inter-dependent communication and collaboration with the patient, caregiver, physician, post acute care providers, and other members of the health care management team.  Assists in identifying appropriate providers/vendors to promote improvement and/or maintenance of the physical, functional, emotional and social well-being of the patient and to enhance coping skills of family members/caregivers.  Key duties include responsibility for easing the transition from hospital setting to the medical home.  Follow up on inpatient discharges with telephonic patient assessments and ensuring continuity of care. Models appropriate behavior as exemplified in The Methodist Mission, Vision, and Values.



Education/Formal Training

Work Experience





Graduate of an accredited school of nursing.


Effective August 1, 2014, new hires (newly hired or rehired at MLH) or current Associates entering this job must also meet one of the following requirements:

  1. Have a Bachelor’s degree or higher in nursing from an accredited program;
  2. Be currently enrolled in an accredited nursing program to complete a BSN or MSN within 3 years of hire date (written agreement required); or
  3. Sign a written agreement to enroll in an accredited nursing program to complete a BSN or MSN within three years of hire date.


One year of job relevant Utilization/Case Management





Home Care Coordination experience.












RN with a current license to practice as a professional nurse in the state where work is performed or compact license.





Case Management certification (ACM, CCM, or certification in progress) is highly preferred.












Bachelor degree (Nursing, Health Care Management, or closely related field) is highly preferred.

Acute care experience preferred.








  • Knowledge of Medicare and other Third Party coverage guidelines.
  • Demonstrated oral and written communication skills required.
  • Demonstrated ability to develop and maintain working relationships with physicians and work collaboratively with health professionals at all levels to achieve established goals.
  • Demonstrated excellent facilitation skills.
  • Ability to plan and schedule tasks and to maintain control of own work flow.
  • General computer skills required, advanced computer skills preferred.
  • Ability to use initiative in decision-making; independent judgment and critical thinking skills.

Key Job Responsibilities

  • Performs and participates as part of the Case Management team to support a collaborative effort for transition planning of care outside the hospital.
  • Promotes quality of care and cost effectiveness through appropriate utilization of resources (fiscal, human, environmental, equipment and service).
  • Identifies patients that meet criteria for care management services through an appropriate screening and assessment process.
  • Facilitates care coordination, collaboration and communication for the patient/family and healthcare team, in order to achieve goals and maximize outcomes throughout the care continuum.
  • Monitors the patient’s progress in achieving the goals, objectives and desire outcomes of the plan of care.
  • Promotes professional practice and accountability for optimal outcomes and continued improvement within the hospital case management scope of practice.

Physical Requirements

  • The physical activities of this position may include climbing, pushing, standing, hearing, walking, reaching, grasping, kneeling, stooping, and repetitive motion.
  • Must have good balance and coordination.
  • The physical requirements of this position are: light work - exerting up to 25 lbs. of force occasionally and/or up to 10 lbs. of force frequently.
  • The Associate is required to have close visual acuity to perform an activity, such as preparing and analyzing data and figures; transcribing; viewing a computer terminal; or extensive reading.
  • Frequent non-invasive patient contact
  • The conditions to which the Associate will be subject in this position: The Associate is not substantially exposed to adverse environmental conditions; job functions are typically performed under conditions such as those found in general office or administrative work.

Nearest Major Market: Memphis

Job Segment: Home Care, Nursing, Medicare, Healthcare