Transition Care Manager - Culver City (RN) in Culver City at Southern California Hospitals

Date Posted: 1/3/2021

Job Snapshot

Job Description

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Transition Care Manager - Culver City (RN)

We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.

Reporting directly to the Director of Clinical Operations and in collaboration with Hospital Administrator, the Post Discharge Care Manager is a key member responsible for managing and oversight of post discharge team and follow up activities for the California Region. This position will be responsible for managing the post-acute care follow up activities of high-risk patients and development of process improvement initiatives related to post discharge.  Ensures the operationalization of clinical procedures and systemized care plans standardizing processes specific to transitions of care working with complex and varied patients and situations. The role supports patients, family members, medical providers and other health care team members through an integrated approach to care coordination and community outreach. Contributes to evidence-based practice and guidelines for delivery of post-discharge activities. Supports new strategic initiatives and organizational mission, vision and goals.

Job Responsibilities/Duties

  • Evaluates and re-evaluates patient response and outcomes and work closely with patient’s medical providers to ensure patients have comprehensive and coordinated post-acute care based on needs and pertinent information identified from outreach. 

  • This includes focus on medication reconciliation and adherence, management of both acute and chronic disease states identification and rectifying gaps in care, assessment, and support of patient’s ability to, perform self-cares, coordination of post discharge appointments and- services (durable medical equipment, home health), and coordination of care.  Ensures post discharge follow up calls within 24-48 hours after hospitalization are conducted.

  • Manages the post discharge activities, acts as resource/liaison to staff, patients, families, and community/others (contracted vendors). Monitors, tracks, and trends issues or concerns identified and ensures timely escalation of unresolved care coordination issues to the appropriate level. Demonstrates ability to problem solve. Complies with standards of practice, HIPPA, and other regulatory agencies.

  • Collaborates with the patient and family to optimize client outcomes. May include working with community, local and state resources, primary care provider, and members of the health care team, payer, and other relevant health care stakeholders to ensure optimal transition of care is achieved. Able to quickly identify and develop solutions to meet patient requirements and needs.  Ensures patient and family receive information on appropriate resources and/or referrals as needed and coordinates consultations with others when needed, prioritizing and optimizing post-discharge activities.

  • Communicates with health care team members as needed. Prepares staff schedules, assist with evaluation, coaching, performance review. Assists with hiring and disciplinary process. Demonstrates management skills coordinating the activities of various health care staff to ensure delivery of proper patient care plan. Able to problem-solve and good analytical skills.

  • Ability to quickly identify and develop solutions to meet patient requirements and needs.

  • Prepares and analyze monthly data and provides detailed report of progress/outcomes. Coordinates, prioritizes, and optimizes post discharge activities. Responsible for the timely reporting of provider performance data which monitors, tracks, and trends issues or concerns identified including documentation of progress and outcomes.  Ensures timely escalation of unresolved care coordination issues to the appropriate level. Demonstrates ability to problem solve.


Minimum Education: Bachelor of Science in Nursing required. Master's degree in Nursing, Business, or related field preferred.

Minimum Experience: Active, current, and unencumbered Licensure as a Registered Nurse in the State of California required.

Req. Certification/Licensure: Minimum five (5) years acute care experience required. Moderate knowledge of CMS regulations and rules governing HCAHPS, Quality and Patient Care required. Previous experience Case Management Experience, knowledgeable with IPAs, payer source, insurance required. Ability to maintain a work pace appropriate to workload, time management skills, and ability to effectively prioritize task. Computer skills, excel, and EMR documentation. Excellent written and verbal communication skills in English. Bi-lingual English/Spanish preferred.

Employee Value Proposition

Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals, benefit eligible positions will receive:

  • Company 401K

  • Medical, dental, vision insurance

  • Paid time-off

  • Life insurance

How to Apply

To apply for this role, or search our other openings, please visit and click on a location to begin your journey to a new career with us!

We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.

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Keywords: Acute Care Hospital, Patient Expereince