Registered Nurse (RN)-Transitional Care Management (TCM) & Medication Reconciliation

Center for Primary Care

Who we are:

For over 30 years the Center for Primary Care (CPC) has cared for families in the CSRA by providing patients with the most convenient, accessible, and personal healthcare available. Our mission is to improve the health and wellbeing of the families we serve by providing compassionate and high-quality care in a joyful setting. The physicians, healthcare professionals, and support team at our 10practices, plus laboratory, imaging, and corporate locations work to transform our mission into action.

What our employees say:

At Center for Primary Care, we understand that the work environment is as important as the hard work you do. Center for Primary Care is Great Place to Work Certified which means our employees share feedback on their work culture experiences and we listen and strive to create positive employee experiences centered on joy, trust, and belonging.

Learn more about CPC’s culture and Great Place to Work Certification by clicking on the link below:

Working at Center for Primary Care | Great Place To Work®

Benefits for you and your family:

Coverage that cares for body, mind, and spirit.

Retirement plan with generous employer match and profit sharing.

Mental Health Support Services.

PTO and Paid Parental Leave.

Scheduled Bonuses.

Registered Nurse (RN)-Transitional Care Management (TCM) & Medication Reconciliation

The Transitional Care Management (TCM) Registered Nurse is responsible for coordinating post-discharge care to reduce hospital readmissions, improve patient outcomes, and support quality measures. The RN performs medication reconciliation, patient outreach, care coordination, and education for patients transitioning from inpatient, observation, skilled nursing, or rehabilitation settings back to the community. The RN collaborates with providers, care teams, caregivers, pharmacies, and community resources to ensure safe and effective transitions of care.

Key Responsibilities:

Essential Functions

Medication Reconciliation

•     Review hospital discharge summaries and medication lists.
•     Complete comprehensive medication reconciliation within required timeframes following discharge.
•     Identify and resolve medication discrepancies, duplications, omissions, contraindications, and adherence concerns.
•     Collaborate with providers and pharmacists regarding medication-related issues.
•     Educate patients and caregivers on medication changes, dosing, side effects, and adherence strategies.

Transitional Care Management

•     Conduct post-discharge outreach calls within required TCM timelines.
•     Assess patient understanding of discharge instructions and treatment plans.
•     Evaluate symptoms, barriers to care, and risk factors for readmission.
•     Schedule and coordinate timely post-discharge provider appointments.
•     Ensure completion of TCM documentation in the electronic health record.
•     Support billing requirements related to TCM services.

Care Coordination

•     Communicate with hospitals, skilled nursing facilities, home health agencies, specialists, and primary care providers.
•     Coordinate referrals, diagnostic testing, home services, and community resources.
•     Escalate clinical concerns to providers as appropriate.
•     Track patient progress through the post-discharge period.

Patient Education

•     Reinforce discharge instructions and disease-specific education.
•     Promote self-management and adherence to care plans.
•     Provide education regarding red-flag symptoms and when to seek medical attention.
•     Support patients and caregivers in navigating the healthcare system.

Quality and Performance

•     Monitor and support reduction of avoidable readmissions and emergency department utilization.
•     Maintain compliance with CMS, payer, and organizational requirements.
•     Participate in quality improvement initiatives and population health programs.
•     Maintain accurate and timely documentation.

Knowledge, Skills, and Abilities Required:

•     Strong understanding of chronic disease management and care transitions.
•     Knowledge of CMS Transitional Care Management requirements.
•     Excellent communication and patient education skills.
•     Ability to prioritize multiple tasks and manage a high-volume patient panel.
•     Strong critical thinking and problem-solving abilities.
•     Proficiency in EMR documentation and care management software.
•     Knowledgeable of electronic medical record system and Microsoft Office suite.
•     Ability to work both independently and in a team environment.
•     Effective verbal and written communication skills.
•     Demonstrates, through behavior, Center for Primary Care’s Mission Statement.
•     Takes responsibility for providing exceptional customer service.
•     Maintains patient confidentiality at all times; adheres to all HIPAA guidelines.
•     Follows CPC guidelines, infection prevention practices, demonstrates appropriate use of PPE, performs hand washing according to policy, and follows safety and workplace incident procedures.
•     Performs miscellaneous job-related duties as assigned.

All essential functions must be performed. Reasonable accommodations may be made to enable individuals with qualified disabilities to perform the essential functions. The above information is intended to describe the general nature and level of work being performed by people assigned to this job. It is not intended to be an exhaustive list of responsibilities, duties and skills required of personnel so classified. Examples listed do not preclude the performance of other duties similar in nature or in level of complexity.