Job Description

Facility: Valleywise Health Medical Center

Department: Care Management

Schedule: Regular FT 40 Hours Per Week

Shifts: Days

Under the direction of the Director of Care Management the RN Care Transition Coordinator (CTC) is accountable for identifying, stratifying, and addressing the needs of high risk populations encountered during inpatient hospitalization.  The RN CTC will be responsible for establishing and managing populations of high risk and other assigned populations at Maricopa Medical Center (MMC) in a manner that aligns with the regulations of the Center for Medicare and Medicaid Services (CMS) and the Arizona Health Care Cost Containment System (AHCCCS).  This position is responsible for anticipating, monitoring, and intervening as indicated to address population and individual health needs across the continuum of health care in order to improve quality and maintain standards set by CMS and State Medicaid Programs.  The RN CTC will assist patients in all areas related to transitioning from an inpatient stay to a post-acute setting, including the home, home healthcare, post-acute facility, or other setting. The RN CTC is responsible for ensuring effective patient education and acts as a resource to answer patient questions. The RN CTC will also schedule and track follow-up appointments and work with patients to ensure psychosocial management and other support following discharge.




  • Requires Bachelor's degree in Nursing.


  • Must have a minimum of three (3) years of acute clinical experience as an RN that demonstrates an understanding of the required knowledge, skills, and abilities.
  • Prefer prior experience in ambulatory nursing and/or hospital case management or equivalent.

Specialized Training:

  • None


  • Must possess a current, valid AZ RN license; temporary AZ RN license; or valid compact RN licensure for current state of practice.  Must also be in good standing with the issuing Board of Nursing.
  • Within two years of hire, requires a Care Coordination Transition Management (CCTM), Accredited Case Manager (ACM), or Case Management (CM) or equivalent certification.

Knowledge, Skills & Abilities:

  • Must be able to demonstrate knowledge of chronic disease states, preventative and wellness management practices and pathways, Valleywise Health policy and procedures, and regulatory standards ensuring high quality and safe standards of care.
  • Must exhibit competency in Microsoft Office software programs and other software systems once trained.
  • Required to possess analytic skills to support data and trend evaluation.
  • Must be a self-starter, demonstrate self-direction and work independently with minimal supervision.
  • Expected to work in a fast paced setting.
  • Must demonstrate professionalism, team work, critical thinking skills and serve as a professional role model.
  • Essential to possess excellent customer service and phone skills with the ability to communicate well, build rapport and collaborate with patients, internal and external clients in order to meet quality outcome goals.
  • May be expected to assist other Care Coordinator RNs in the hospital.
  • Has valid driver's license and driving record showing no restrictions that would impede ability to travel by automobile.
  • Demonstrated computer literacy required with basic to intermediate knowledge of Microsoft Office applications including Word, Excel and Powerpoint.
  • Experience with databases is preferred.
  • Must be able to read, write and speak effectively in English. Bilingual Spanish speaking is preferred.

Application Instructions

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