Transitional Care Manager, RN

Overview

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.

• 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.

• 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.

• 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: 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.