Registered Nurse Case Manager -

Transitional Care Date Posted:

3 October 2026

Closing Date:

November 2, 2026

Recruiter:

MedStar Health Location:

Rosedale, Maryland Salary:

USD93,000

to

USD118,000

Job Type & Industry:

Technology Risk Contract Type:

Permanent Job Reference:

3003329467-2 Apply for this job now Job Description As an RN Case Manager - Transitional Care at MedStar Health, you will coordinate safe, patient-centered transitions from hospital to home or post-acute settings. You'll assess clinical and psychosocial needs, develop individualized discharge and care plans, and collaborate with physicians, social workers, and community providers to reduce readmissions and improve outcomes. Using evidence-based protocols, you educate patients and families, arrange services, monitor progress, and advocate for resources across our regional health system to ensure continuity, quality, and a positive patient experience. Responsibilities Conduct comprehensive clinical and psychosocial assessments to support safe transitions of care. Develop and implement individualized discharge and transitional care plans. Coordinate services with physicians, nurses, social workers, and community providers. Educate patients and families on diagnoses, medications, and self-management after discharge. Arrange home health, DME, rehab, and community support resources. Monitor high-risk patients post-discharge to reduce avoidable readmissions. Advocate for patient needs and appropriate level of care and services. Document assessments, plans, and outcomes in the EHR accurately and timely. Use evidence-based protocols and metrics to improve quality and patient experience. Participate in interdisciplinary rounds and performance improvement initiatives. Required Skills Transitional care management Hospital discharge planning Clinical assessment Care coordination Utilization management Patient and family education Interdisciplinary team collaboration Electronic health records (EHR) Community resource navigation Data and outcomes tracking