Transitional Care Manager, RN

The Transitional Care Manager (TCM) nurse is an RN responsible for reducing preventable hospital readmissions and improving health outcomes for high-risk patients transitioning from inpatient facilities (hospital, SNF, rehab) back to the community. The TCM RN provides intensive, short-term case management during the critical 30-day post-discharge period and works to ensure smooth coordination with primary care, specialty services, behavioral health, and community resources.Essential Job Duties:Conduct timely post-discharge outreach (within two business days of discharge) via telephone, tele-health, or in-person visit to patients discharged from inpatient or observation settings.Perform comprehensive medication reconciliation, symptom assessment, red-flag identification, and individualized care planning.Schedule and ensure attendance at follow-up face-to-face primary care appointment, ideally within 7 days, but no greater than 14 days.Coordinate care with hospitals, specialists, home health agencies, DME providers, behavioral health, and social services.Identify and address social determinants of health barriers (housing, food insecurity, transportation, caregiver support, etc.) and connect patients to internal and community resources.Provide patient/self-management education on disease processes, medications, warning signs, and when to seek help.Document all activities in the EHR according to CMS Transitional Care Management (TCM) billing requirements (99495/99496) and organizational standards.Participate in interdisciplinary case conferences and quality improvement initiatives focused on reducing readmissions and avoidable ED visits.Mentor and support medical assistants and community health workers involved in post-discharge follow-up.Maintain Healthcare Basic Life Support as required for the role.Other duties as assigned.Qualifications:Active Registered Nurse license in North Carolina required.Minimum 2 years of experience in case management, care coordination, discharge planning, or transitional care (hospital or ambulatory setting) preferred.Experience working with underserved, low-income, or multicultural patient populations strongly preferred.Experience in an FQHC, FQHC Look-Alike, or community health center environment.Proficiency with Epic preferred.Basic Healthcare BLS certification.Behavioral Expectations and Performance Skills:Excellent clinical assessment, critical thinking, and prioritization skills.Ability to work independently while functioning as part of an interdisciplinary team.Exceptional communication and patient engagement skills (telephone and in-person).Knowledge of social determinants of health and community resources in Madison County and surrounding areas.Proficiency in Microsoft Office and EHR documentation.Education and Experience:Education: Graduate of an accredited school of nursing, BSN, or an advanced practice RN, and currently holding an RN license in the State of North Carolina.Experience: Minimum two years of case management, home health care, hospice, or related experience in adult and pediatric populations.Other: Valid N.C. Driver’s License, proof of auto liability insurance, and dependable.

Salary : $30 - $40