Transitional Care Management Nurse

About the role

The Transitional Care Management Nurse is a BSN‑prepared registered nurse who exercises advanced clinical judgment and operates at the top of their license to guide complex, high‑risk patients through critical transitions of care over a 30‑day period. This role is pivotal in preventing readmissions, optimizing patient outcomes and experience, and ensuring seamless care coordination across settings. The nurse serves as the primary point of contact for patients and families, providing comprehensive oversight and support during the vulnerable post‑discharge phase.

Responsibilities

• Conduct comprehensive clinical assessments of high‑risk patients at discharge and throughout the 30‑day transitional care period, identifying medical, psychosocial, and environmental risk factors.
• Develop, implement, and continuously update individualized, patient‑centered care plans addressing clinical needs, medication management, and follow‑up care.
• Coordinate care and facilitate timely communication among inpatient providers, primary care, specialists, home health agencies, and community resources.
• Serve as the primary point of contact for patients and families, providing education on disease management, medications, symptom monitoring, and escalation protocols.
• Manage a caseload of post‑discharge patients and ensure completion of follow‑up appointments, home visits, and adherence to prescribed treatments.
• Lead and participate in interdisciplinary rounds and case conferences, collaborating with physicians, pharmacists, social workers, behavioral health providers, and nursing staff.
• Monitor patient progress through outreach visits, telehealth, and phone contacts, intervening promptly when clinical or psychosocial issues arise.
• Ensure compliance with CMS Transitional Care Management guidelines, Joint Commission standards, and organizational policies through accurate and timely documentation.
• Participate in quality improvement initiatives and identify opportunities to strengthen transitional care workflows and patient outcomes.
• Perform other duties and responsibilities as assigned.

Requirements

• Education: Bachelor of Science in Nursing (BSN) required.
• Certification/Registration/License: Active, unrestricted Registered Nurse (RN) license.
• Work Experience: Minimum of five years of clinical nursing experience in acute care, discharge planning, post‑acute care, or transitional care.
• Minimum of three years of experience providing care and patient education to complex populations, including heart failure, COPD, GI bleed, sepsis, or stroke.
• ED/Triage/CM experience preferred.

Qualifications

• Education: Master of Science in Nursing or related field preferred.
• Certification/Registration/License: Preferred certifications include Medical‑Surgical RN (MEDSURG‑BC), Cardiac‑Vascular Nursing (CV‑BC), or Nursing Case Management (CMGT‑BC).
• Experience: Additional experience in transitional care or case management preferred.

Skills

• Advanced clinical expertise in complex patient management and transitional care.
• Strong care coordination, critical thinking, and clinical decision‑making skills.
• Demonstrated leadership in interdisciplinary collaboration and patient advocacy.
• Strong communication skills, including use of motivational interviewing techniques.
• Proficiency with electronic health records, care coordination tools, and telehealth platforms.
• Knowledge of regulatory requirements and reimbursement criteria related to transitional care.
• Strong organizational, analytical, and prioritization skills.
• Commitment to ethical practice, patient‑centered care, and continuous professional development.

Benefits

• Benefits Eligible: Yes.
• Total Rewards include competitive compensation, premium pay (shift, on‑call, etc.), incentive pay for select positions, and opportunity for annual increases based on performance.
• Paid Time Off programs.
• Health and welfare benefits: medical, dental, vision, life, short‑ and long‑term disability.
• Flexible Spending Accounts for eligible health care and dependent care expenses.
• Family benefits: adoption assistance and paid parental leave.
• Defined contribution retirement plans with employer match and other financial wellness programs.
• Educational Assistance Program.
• Note: Eligibility for programs may depend on FTE or status (full‑time, part‑time, per diem, temporary, etc.).

Pay

Pay Range: $38.20 - $57.30

Schedule

Hours Per Week: 20 (0.5 FTE). Remote work‑from‑home position; high‑speed internet required. Must live within 1 hour of Mint Hill. Covers every weekend from