Hospital Discharge Care Manager (RN or LPN)

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Bayless Integrated Healthcare is committed to improving lives and transforming healthcare. We utilize our Core Values as the foundation for all we do:

COMPASSIONATE: Compassion is the humane quality of understanding the needs of others, and wanting to do something about it. We show kindness and a willingness to help others. We always provide care for our colleagues, our patients and our community.

ADAPTABLE: The ability of our team to adapt to different environments, conditions and changes is imperative to deliver high quality care. Adaptable people are open to others while realizing the impact of their own words, tone and body language on others.

INNOVATIVE: Our team must have creative and critical thinking in order to introduce new ideas. Our commitment is creating a comprehensive healthcare delivery system like nothing done, experienced or created before.

RELIABLE: As a patient and community centric organization, being reliable is of the utmost importance. In order to achieve results, we must have a team comprised of consistent and trustworthy individuals that can be counted on to follow through.

RELENTLESS: We have an unwavering commitment to improve the healthcare system, disrupt the status quo, and create a better community. We are driven individuals that exemplify intensity and the pursuit of excellence. A strong work ethic and enthusiasm are necessary in order to help our patients, improve our community, and accomplish our goals.


The Care Manager on the hospital team reports to the Manager of Integrated Care and is part of the population health department. The responsibility of the Care Manager is to engage patients who are being discharged from a hospital because of a behavioral health and/or medical condition(s) and coordinate their transition to outpatient care. The goals of this position are to reduce symptom relapse, decrease percentage of hospital re-admission, increase patient knowledge and self-management of their conditions, and coordinate/reconcile medications. In addition, this position will assist with medication education, psychoeducation, and taking vitals. The Care Manager will also administer screenings, assessments, and referrals for ongoing primary care, behavioral health, psychiatric and other specialist appointments. This position will support the patients transition from the hospital to home care via virtual, telephonic, and face-to-face appointments in the hospital, community, patients residence, and in the clinics.


* Provide transition planning and support for patients post hospitalization to prevent re-hospitalization

* Provide psychoeducation of diagnosis/disease management/medication

* Meet with patient in variety of settings (e.g. home, community, office, etc.) and provide nursing support as needed (e.g. Vitals, medication management)

* Initiate care conferences to discuss multidisciplinary team responsibilities, patient progress, recommendations and concerns

* Perform follow-up calls for patients recently discharged from acute hospitalizations and who are high risk for readmission

* Determine and complete appropriate referrals; serve as a liaison to providers, patients and families for the coordination of services

* Maintain accurate and timely documentation in EMR and other healthcare databases

* Serve as a patient and family advocate giving priority to customer service issues and promoting positive interpersonal relationships among patients, providers, and the community

* Assist patient with overcoming barriers with attending scheduled appointments

* Identify high risk patients and refer to appropriate team for ongoing support



* Registered Nurse with Active and current licensure by the AZ State Board of Nursing or

* Licensed Practical Nurse with active and current licensure by the AZ State Board of Nursing

* Experience with behavioral health population preferred

* Experience with hospital discharge planning preferred


* The ability to use a phone, computer, printer, and copier is required.

* Frequent use of Microsoft office products, including but not limited to Outlook, Word, Excel, and PowerPoint.

* The ability to use the internet and various web browser software is required.
  • 1
  • Negotiable
  • None
  • None
  • Re-87745
  • Permanent
  • 3

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