RN Case Manager

Job Title: RN Case Manager

Location: Trinity Health Ann Arbor Hospital, Michigan 48197

Schedule: Monday–Friday, 8:00 AM–5:00 PM

Contract Duration: 12+ months

Position Summary

The Case Manager RN coordinates care for health plan members, ensuring their clinical, psychosocial, and social needs are addressed throughout the care continuum.

As part of the onsite pilot at Trinity Health Ann Arbor Hospital, the RN serves as a link between the hospital and the health plan, supporting safe hospital discharge, identifying barriers to recovery, coordinating resources, and facilitating timely handoffs to the Medicare Advantage Care Management team for post-discharge Transitions of Care (TOC) outreach.

Key Responsibilities

• Collaborate with hospital care managers, discharge planners, providers, and health-plan care management teams to support safe and timely discharge.
• Identify eligible Medicare Advantage members who may benefit from additional transition support.
• Assess clinical, functional, psychosocial, and social needs that may affect the transition home.
• Identify and coordinate solutions for barriers involving medications, follow-up appointments, transportation, durable medical equipment (DME), caregiver support, nutrition, and benefits.
• Educate members and caregivers on discharge instructions, medication plans, warning signs, and follow-up care, using teach-back as appropriate.
• Escalate unresolved clinical, safety, and discharge-related concerns through established workflows.
• Complete accurate, timely documentation of assessments, interventions, unresolved barriers, and follow-up needs.
• Provide clear clinical handoffs to the Medicare Advantage Care Management team to support timely TOC outreach.
• Coordinate multidisciplinary care, connect members with appropriate resources, and monitor progress toward care goals.
• Participate in pilot huddles, case reviews, and workflow improvement activities while maintaining HIPAA compliance and professional standards.

Role boundary

The RN supports discharge coordination but does not replace the hospital's clinical assessment, discharge planning, ordering responsibilities, or medical decision-making.

Education and Experience

• Nursing diploma or Associate Degree in Nursing required; BSN strongly preferred.
• Minimum of three years of clinical nursing experience in clinical, acute/post-acute care, and community settings required.
• One year of managed-care case management experience strongly preferred.
• Experience with telephonic and digital patient management preferred.

Licensure and Certifications

• Active, unrestricted Michigan RN license required.
• Certified Case Manager (CCM) required or to be obtained within 18 months of hire.
• Certified Chronic Care Professional (CCP) preferred.

Required Skills

• Strong clinical judgment, critical thinking, and problem-solving skills.
• Excellent communication, active listening, and member engagement skills.
• Proficiency in motivational interviewing and patient education.
• Strong organization, time management, and documentation skills.
• Ability to collaborate with multidisciplinary teams and work independently.
• Intermediate computer skills and proficiency in Microsoft Office applications, including Excel, Word, Outlook, OneNote, and Teams.

Pay and Benefits

• $35-$39 per hour
• 9 days of Paid Time Off
• Health Insurance (Medical, Dental and Vision)

Pay: $35.00 - $39.00 per hour

Expected hours: 40.0 per week

Benefits:

• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Experience:

• Registered Nurse: 5 years (Required)
• Case Manager: 2 years (Required)

License/Certification:

• Michigan State Registered Nurse License (Required)

Ability to Commute:

• Ypsilanti, MI 48197 (Required)

Work Location: In person