Remote Transitional Care Registered Nurse

Job Description

Job Description

Position Summary

DaMar Staffing Solutions is seeking a compassionate and highly skilled LTSS RN Coordinator – Clinician to support individuals transitioning from inpatient settings such as emergency departments, hospitals, skilled nursing facilities, or nursing homes. This is a remote position, and candidates must reside in the state of Indiana.

This role is critical in facilitating person-centered care planning and ensuring continuity of care during transitions. The LTSS RN Coordinator serves as a clinical liaison and advocate for patients, working closely with LTSS Coordinators, contracted providers, and interdisciplinary teams to promote safe, efficient, and high-quality care.

This position focuses on building trusting relationships with members and their families, preventing unnecessary readmissions, providing geriatric support, and optimizing the use of healthcare resources.

Key Responsibilities

• Conduct virtual and telephonic outreach to patients, providers, and stakeholders involved in transitions of care.

• Serve as a patient advocate to resolve barriers and ensure access to needed services and resources.

• Collaborate with LTSS service coordinators and clinical teams to identify risks and ensure alignment with the Person-Centered Service Plan (PCSP).

• Engage hospital staff (e.g., physicians, case managers, discharge planners) to support timely, safe discharges and effective post-acute care planning.

• Participate in case reviews, discharge planning meetings, and facilitate communication across the care continuum.

• Review medical records and utilization data to ensure appropriate care and identify discharge barriers.

• Provide education and support to patients and families regarding care plans, discharge instructions, medications, follow-up care, and available community resources.

• Complete structured clinical assessments to determine post-discharge needs, including medical equipment, follow-up appointments, home health services, and caregiver support.

• Ensure documentation and tracking of transition interventions comply with internal protocols and external regulatory requirements (CMS, NCQA, and state-specific).

• Report critical incidents to appropriate regulatory or state agencies when required.

• Participate in member grievance or appeals processes, audits, and hearings as necessary.

• Offer mentorship and training to new staff as needed and support quality improvement initiatives.

Minimum Qualifications

• Active Registered Nurse (RN) license in the state of Indiana, in good standing.

• Must reside in Indiana.

• Minimum of 2 years of clinical experience in transitional care, emergency department, discharge planning, or home health settings.

Preferred Qualifications

• Strong knowledge of Medicaid, NCQA standards, and transitions-of-care protocols.

• Familiarity with inpatient care management and utilization review processes.

• Strong communication skills and ability to engage effectively with patients, families, and multidisciplinary healthcare teams.

• Ability to identify cost-effective care strategies that support high-quality outcomes.

• Proficiency with documentation and clinical recordkeeping systems.

• Independent problem-solving skills with a proactive, patient-centered approach.

• Company preference for RNs residing in Marion County.

Company DescriptionDaMar Staffing Solutions of Indianapolis (“DaMar”) is a premier boutique recruitment firm. The DaMar model offers on demand solutions at an affordable price. DaMar Staffing Solutions is the place for professional level staffing for all industries .

Company Description

DaMar Staffing Solutions of Indianapolis (“DaMar”) is a premier boutique recruitment firm. The DaMar model offers on demand solutions at an affordable price. DaMar Staffing Solutions is the place for professional level staffing for all industries .