Los Angeles, CA (Hybrid)
The RN Case Manager – LTAC Transitions facilitates safe, timely, and well-coordinated transitions of patients from Long-Term Acute Care (LTAC) settings to lower—but medically appropriate—levels of care, including skilled nursing facilities, sub acute units, or home and community-based programs.
Working within a hybrid model, the Coordinator spends designated days on-site at partner LTACs to participate in care rounds, engage with discharge planners, and coordinate directly with facility teams, while performing administrative and follow-up tasks remotely on non-onsite days.
This position serves as the operational bridge between LTAC staff, Presidium providers, external facilities, and community partners—ensuring continuity, compliance, and strong communication across all transitions of care.
Compensation: $60,000 – $110,000 annually
Schedule: Full-time
Benefits: 3 weeks paid time off (2 weeks + 6-7 federal holidays), 401K, Medical, Dental, and Vision.
Onsite (LTAC-Facing) Responsibilities
Attend scheduled onsite days (typically 2–3 per week) at assigned LTAC facilities.
Participate in interdisciplinary rounds and discharge planning meetings on behalf of Presidium.
Serve as the point of contact for LTAC case managers, social workers, and clinical staff regarding patients attributed to Presidium.
Review provider discharge readiness decisions and ensure orders, documentation, and authorizations are initiated promptly.
Identify barriers to discharge (e.g., authorization delays, placement availability) and escalate to the Director of Care Management or supervising provider.
Support family and caregiver education on post-discharge instructions, follow-up appointments, and care continuity resources.
Remote (Administrative & Follow-Up) Responsibilities
Complete discharge documentation, coordination notes, and communication logs in the EHR or designated coordination platform.
Arrange logistics including transportation, DME, pharmacy coordination, home health orders, and post-discharge appointments.
Communicate with SNFs, home health agencies, and community partners to ensure readiness to receive the patient.
Confirm successful transfers and monitor members for 30-day readmission or escalation risk.
Conduct post-transition outreach calls to verify continuity and patient satisfaction.
Coordinate with internal ECM and Community Supports teams for warm handoffs into ongoing wraparound programs.
Cross-Functional Collaboration
Collaborate closely with Presidium providers and interdisciplinary teams to align discharge plans with the patient’s clinical needs and social circumstances.
Communicate proactively with health plans or managed care organizations to confirm authorizations or clarify next-level placement requirements.
Participate in internal quality-improvement initiatives focused on readmission prevention and transition efficiency.
Maintain compliance with HIPAA, CMIA, and all internal privacy and data security policies.
Documentation and Reporting
Ensure all transition and coordination notes are entered within 24 hours of activity.
Track and report transition status metrics (timeliness, barriers, outcomes) through dashboards or assigned templates.
Support monthly performance review meetings by providing updates on active transitions, resolved barriers, and quality indicators.
Education & Licensure Requirements
Preferred: Registered Nurse (RN) or equivalent clinical training.
Minimum: Associate degree in Nursing, Health Sciences, Social Services, or related field; or equivalent combination of education and healthcare coordination experience.
Desirable: Bachelor’s degree (BSN, BA/BS in Health Administration, Public Health, or Social Work).
Valid California driver’s license and reliable transportation (for travel to partner LTAC facilities).
Experience Requirements
Minimum 3 years’ experience in care coordination, discharge planning, or case management within LTAC, acute hospital, SNF, or managed-care environment.
Experience coordinating services and authorizations with health plans, providers, and community partners.
Familiarity with CalAIM, ECM, or Community Supports preferred.
Strong interpersonal skills with the ability to communicate effectively across clinical and administrative teams.
Highly organized with the ability to manage multiple transitions and shifting priorities in a fast-paced environment.
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