RN Case Manager, Transition of Care (TOC) – PG County

Cityblockhealth is hiring a full-time Registered Nurse Case Manager specializing in Transition of Care in Prince George's County. You'll coordinate seamless care journeys for patients moving between healthcare settings, ensuring continuity, safety, and optimal health outcomes.

About the Role

Transition of Care case management sits at the intersection of clinical expertise and care coordination. In this position, you'll serve as the clinical bridge for patients navigating complex transitions—from hospital discharge to home recovery, to skilled nursing facilities, or other care environments. Your goal is to ensure every patient has a clear plan, strong support, and access to the resources they need to succeed outside the acute care setting. You'll work within a collaborative team of healthcare providers, social workers, and community partners to reduce avoidable readmissions and improve patient outcomes across Prince George's County.

Your Responsibilities

• Conduct comprehensive clinical assessments of patients at transition points to identify needs, risks, and barriers to successful care continuity
• Develop and implement individualized care plans that address medical, social, and behavioral health requirements
• Coordinate communication between hospital teams, primary care providers, specialists, and post-acute care settings
• Perform timely follow-up outreach to ensure patients understand their discharge instructions and have established care continuity
• Advocate for patient needs and facilitate access to community resources, home health services, and social support
• Document case management activities and outcomes in the patient record to support quality improvement and program evaluation

What You Bring

• Active RN license in good standing in Maryland
• Minimum clinical nursing experience, preferably in hospital, acute care, or care coordination settings
• Strong interpersonal and communication skills with the ability to engage diverse patient populations
• Familiarity with healthcare systems, insurance processes, and discharge planning
• Ability to prioritize multiple transitions and manage time effectively in a dynamic environment
• Commitment to patient-centered care and health equity

More About Cityblockhealth

Cityblockhealth is a healthcare organization focused on delivering high-quality, community-based care designed to meet patients where they are. We partner with individuals and families to address the social, economic, and health factors that shape wellbeing, working toward sustainable health and stronger communities.

Next Steps

To apply, complete your application directly on this page, or you'll be redirected to the employer's application platform to finish submitting there.