Manager - Transitional Care & Telehealth Services

Position Objective

The Manager of Transitional Care and Telehealth Services is responsible for the strategic development, implementation, and daily oversight of programs that ensure seamless, high-quality, and cost-effective patient transitions across various healthcare settings. This role integrates virtual care methodologies into the transitional care processes to support continuous patient monitoring, education, and support remotely. The manager leads a multidisciplinary team, drives quality improvement initiatives, ensures regulatory compliance, and improves overall patient outcomes and satisfaction while reducing avoidable readmissions.

Essential Duties and Responsibilities

• Program Development & Oversight: Develop, implement, and manage comprehensive transitional care and virtual health programs, including program goals, policies, and workflows.
• Care Coordination: Oversee the coordination of patient care across the continuum, ensuring effective communication and warm handoffs between physicians, nurses, social workers, external providers, and community resources.
• Telehealth Integration: Spearhead the integration of virtual technologies (video conferencing, secure messaging, remote patient monitoring devices) to support patient engagement, chronic disease management, and remote follow-up care during transitions.
• Staff Management & Leadership: Provide leadership, mentorship, and supervision to a team of care coordinators, social workers, and telehealth staff. Assist in recruitment, training, and performance management.
• Patient Advocacy & Education: Ensure patient-centered care models are utilized. Oversee staff in educating patients and their families about care plans, medications, and self-management strategies to empower them in their care.
• Quality Improvement & Compliance: Monitor key performance indicators (KPIs) such as readmission rates, length of stay, and patient satisfaction. Utilize data analysis to identify areas for improvement and ensure adherence to all regulatory standards (CMS, NCQA, state-specific requirements).
• Documentation & Systems: Ensure accurate and real-time documentation within the Electronic Health Record (EHR) and care management systems. Collaborate with IT to optimize systems for information sharing across entities.

Required Qualifications and Skills

• Education: Bachelor’s degree in nursing, Social Work, Healthcare Administration, or a related field. A Master's degree is preferred.
• Experience:
• Minimum of 3-5 years of clinical or case management experience in a healthcare setting (acute care, home health, etc.).
• Minimum of 2 years of supervisory or management experience in a relevant field.
• Experience with telehealth platforms, remote patient monitoring, and EHR systems is essential.
• Licensure/Certification: Current active licensure as a Registered Nurse (RN), Licensed Clinical Social Worker (LCSW), or Licensed Clinical Professional Counselor (LCPC) in the state of practice. Certification in Case Management (CCM) or Transitional Care Management (TCM) is highly valued.
• Required Knowledge and Skills:
• Exceptional communication, interpersonal, and problem-solving skills.
• Strong analytical and data management abilities to drive performance improvement.
• Knowledge of quality improvement approaches and healthcare regulations.
• Ability to work collaboratively with multidisciplinary teams and external partners.

Working Conditions, Equipment, Physical Demands

There is a reasonable expectation that employees in this position will be exposed to blood-borne pathogens. Physical demands include sitting for extended periods, occasional lifting, and exposure to various healthcare environments.

Luminis Health Benefits Overview

• Medical, Dental, and Vision Insurance
• Retirement Plan (with employer match for employees who work more than 1000 hours in a calendar year)
• Paid Time Off
• Tuition Assistance Benefits
• Employee Referral Bonus Program
• Paid Holidays, Disability, and Life/AD&D for full-time employees
• Wellness Programs
• Employee Assistance Programs and more

Location

Annapolis, MD

About Luminis Health

A waterfront city with a rich history, Maryland’s capital has something for everyone. A career with Luminis will help you make the most of it.

Our Vision

We believe that health and wellness are fundamental to everyone.

Our Leaders

Get to know our diverse team of leaders who are passionate about bringing quality healthcare to our community.

Vision 2030

Our strategic plan to support our communities and live our healthiest lives together.