The RN Care Manager (RNCM) is an integral member of the transitional/post-acute team. The RN Care Manager works with patients and their families to ensure a smooth transition following discharge from any facility. In addition, the RN Care Manager provides transitional and intensive nurse care management services for the entire network and works collaboratively with the health plan, leadership, department coordinators to ensure the highest quality of patient satisfaction is met.


a. Work directly as a member of the USHS Interdisciplinary Team.
b. Implement and participate in the patient’s plan of care; update and revise as needed.
c. Assist in coordination of comprehensive care; including obtaining referrals to other interdisciplinary services (Home Health, Palliative Care, Social Services) to help prevent further need for acute care utilization.
d. Maintain case load of between 40-60 patients or based on the needs of the client and/or contractual obligation.
e. Conduct face to face visits at a minimum of every 30 days for assigned patients enrolled in Intensive Case Management. May conduct increased face to face or telephonic visits based on the needs of the patient and or contractual obligation.
f. Complete Clinical and Social Assessments (CSA) to develop care plan upon initial start of care visit with patient.
g. Initiate, complete, and update patient care plans as required by USHS and contracted partner standards.
h. Provide communication with patient’s providers and medical specialists regarding patient status and any changes in condition.
i. Participate in weekly scheduled interdisciplinary care team meetings and provide Director of Clinical Services with patient for presentation by Monday at 12pm.
j. Engage with USHS leadership and contracted providers to resolve changes in patient status, complaints, or complications though participation in weekly ICT meetings.
k. Complete medical reconciliation for all transitional care patients within 30 days of initiation of TCM contact.
l. Demonstrate knowledge of acute/post-acute community-based care needs through engagement with USHS leadership.
m. Complete other duties as assigned.



a. Know and follow Employee Handbook policies and procedures.
b. Communicate verbally and in writing through proper channels.
c. Maintain patient confidentiality. Be HIPAA compliant by observing HIPAA and group’s guidelines.
d. Use time clock appropriately.
e. Participate in staff meetings.
f. Follow dress code.
g. Notify supervisor in writing when requesting paid time off.
h. Be courteous.
i. Be flexible and adaptable.
j. Promote departmental and organizational goals.
k. Know and follow applicable safety standards.



a. Work Position:

i. Sitting – 10%
ii. Standing – 50%
iii. Walking – 40%

b. Body Movements:

i. Lifting 0-20-pounds; books, reams of paper, files, etc.- 20%
ii. Bending, stooping and squatting- 20%
iii. Reaching above head to 75 degrees less than- 20%
iv. Grip/hand dexterity; writing – 30%
v. Climbing stairs- 10%



a. Language & Communication Skills:

i. Must be able to understand and communicate in English language.
ii. Must be able to communicative effectively with patients, families, internal/external providers.
iii. Communicate and understand the features of Medicare, Medicaid and other contracted insurance providers.

b. Decision Making:

i. Ability to make clinical decisions for routine patient care and critically think to assist patient with complex medical issues.

c. Computer Skills:

i. Must have basic computer skills, including use of Microsoft Word and Office.
ii. Must master use of Care Pointe care management proprietary software.

d. Problem Solving:

i. RN Case Managers must be able to multitask and handle numerous responsibilities throughout each day.



a. Current, unencumbered, Registered Nurse License and graduation from an accredited Registered Nursing program required.
b. Current BLS/CPR certification required.
c. Current TB test and maintain a negative test annually required.
d. Arizona Fingerprint Clearance Card required.
e. Hep B vax/titer proof (Company does offer/or may sign a declination) required.
f. Current flu shot (or sign waiver/follow mask policy) required.
g. Having an in-depth knowledge of health care services and other medical terminology is a required.


This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned, and management retains the right to add or change the duties at any time. The above expectations have been explained and discussed with me. I understand that my performance will be evaluated based upon these expectations.

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