Senior Manager, RN, Care Transitions

Avail Health is launching a hospital-based Care Transitions Program supporting Medicare patients with complex medical, behavioral health, and social needs following discharge. The Senior Manager, RN is the frontline clinical leader of that program — the primary on-site representative of Avail Health within the hospital and the day-to-day leader of the interdisciplinary Care Transitions team.

You’ll work on the hospital floor identifying eligible patients, conducting assessments, supporting enrollment, and building the working relationships with hospital care management teams that make the program run. You’ll lead daily virtual huddles with the remote team — NP, RN Care Manager, SW Care Manager, and Care Coordinators — managing panel priorities, escalations, and coordination workflows. You’ll provide direct people management and clinical oversight for the team, and partner closely with the Senior Operations Manager and executive leadership on program performance and growth.

This is a founding leadership role. You’re not inheriting a built program — you’re standing one up.

•  Day-to-day clinical leadership and people management of the interdisciplinary Care Transitions team

•  Hospital-side patient identification, assessment, enrollment, and warm handoff workflows

•  Hospital partnership relationships and Avail Health’s on-site presence and reputation

•  Serve as the primary on-site Avail Health representative within the hospital — participating in huddles, rounds, and discharge planning discussions to identify eligible patients

•  Engage patients and caregivers directly in the hospital to conduct assessments, support program enrollment, and coordinate transition planning

•  Apply advanced clinical judgment to rapidly assess medical, behavioral health, psychosocial, and environmental risk factors; risk-stratify patients and mobilize the right interdisciplinary resources

•  Lead daily virtual huddles with the remote Care Transitions team; manage panel priorities, escalations, and cross-team coordination

•  Provide direct people management, coaching, and clinical oversight for assigned team members

•  Partner with the Senior Operations Manager on workflow implementation, operational readiness, quality monitoring, and program development

•  Conduct occasional mobile in-person visits post-discharge; provide coverage and clinical support for team RNs as needed

•  Partner with executive leadership on program performance, hospital partnership strategy, and scaling initiatives

•  Eligible patients identified and enrolled from hospital discharge lists at or above program targets

•  30-day readmission rate for enrolled Care Transitions patients at or below program benchmarks

•  Hospital partnership relationships strong, with high satisfaction from care management leadership and frontline staff

•  TCM episode compliance — outreach timeliness, visit completion within CMS window — at or above requirements across the full team panel

•  Care Transitions team operating with clear accountability, strong engagement, and consistent performance against quality metrics

Required:

•  Active, unrestricted Maryland RN license in good standing; current BLS certification

•  5 years of clinical RN experience including mobile care delivery (home health, hospice, or house calls) and post-hospital transitions, discharge planning, or complex care coordination for high-risk populations

•  2 years of experience supervising, coordinating, or leading clinical staff or interdisciplinary care teams in a fast-paced healthcare environment

•  Demonstrated ability to rapidly assess and prioritize complex clinical, behavioral health, psychosocial, and environmental risk factors impacting safe transitions

•  Strong relationship-building skills with hospital stakeholders, patients, caregivers, and interdisciplinary teams

•  Excellent organizational and time management skills with ability to manage competing priorities in a startup-style environment

Preferred:

•  Experience in hospital care management, discharge planning, TCM, or readmission reduction programs

•  ED, observation, rapid assessment, triage, or other high-acuity care coordination experience strongly preferred

•  Experience with Medicare-aged populations with complex medical, behavioral health, or psychosocial needs

•  Experience supporting clinical operations, program implementation, or startup launches in partnership with operational or executive leadership

Work Type: Primarily in-person, hospital-based; limited remote for administrative and leadership activities

Schedule: Monday–Friday, 8:00 AM – 5:00 PM ET with flexibility for operational needs; occasional on-call as program scales

Travel: Daily on-site presence required; occasional mobile visits across Montgomery County; must reside within commuting distance of Rockville

Autonomy: High — frontline leadership role with direct executive partnership and significant ownership of program outcomes

Salary Range: $117,500 – $147,500 annually, commensurate with experience

Key Benefits:

•  Medical, dental, and vision insurance

•  HSA | 401(k) with employer match

•  15 days PTO | 8 1 floating holidays

•  Professional liability and malpractice insurance provided

•  All devices for clinical and technology-related activities provided

Avail Health is a Nurse Practitioner–founded organization delivering mobile and virtual care to Medicare-age patients. We combine technology, operational rigor, and clinical excellence to improve outcomes for complex populations. For more visit www.availhealthcare.co