Transitional Care Management Nurse (TCMN)

Monday–Friday, 8 am–5 pm EST (possible rotating weekend coverage). Fully remote; all work equipment provided by the company.

About the role

The Transitional Care Management Nurse (TCMN) provides telephonic outreach to patients within two business days of their discharge from a hospital or Skilled Nursing Facility. The TCMN may also use other outreach methods such as the Patient Portal or letters as appropriate. Responsibilities include patient assessment, support for treatment regimen adherence and medication management, education for patients and family members to promote self-management and independent living, and communication with the patient’s care team to ensure coordinated and safe transitions back to the community.

Responsibilities

• Access and navigate hospital EMR systems to obtain daily patient discharge lists and medical records.
• Review hospital discharge lists to identify patients discharged to Skilled Nursing Facilities or Rehab.
• Send notifications to SNFs regarding Millennium patient admissions and request discharge notifications from SNFs.
• Perform patient outreach calls within two business days of hospital or SNF discharge (two call attempts).
• Conduct telephonic assessments and provide education and support for treatment regimen adherence and medication management.
• Identify potential care gaps and make referrals as appropriate.
• Identify available community services and health resources, facilitating access to care for patients and families.
• Notify the Primary Care Provider or staff of any urgent patient needs or concerns.
• Schedule TCM face-to-face visits with the PCP or Advanced Practitioner.
• Arrange home visits by ARNPs for homebound patients unable to visit the PCP’s office.
• Respond to TCM patient phone calls in a timely manner.
• Document all patient encounters in the electronic medical record.
• Update and maintain the TCM Spreadsheet daily.
• Attend all required team and staff meetings.

Requirements

• Completion of an accredited LPN program and a current Florida LPN License preferred.
• Two years of related experience and/or training, or an equivalent combination of education and experience.

Benefits

• 3 weeks PTO and 8 paid holidays.
• Medical, dental, and vision coverage.
• Employer-paid basic life and short-term disability insurance (effective after one year of full-time employment).
• 401(k) with company match.
• Employee wellness programs.
• Employee discount programs (e.g., Tickets at Work, cell phone discounts).
• Additional voluntary benefits: Dependent Care FSA, Voluntary Life, Long-Term Disability, Critical Illness, and Pet Insurance.

Pay

Compensation range: $22.99 to $34.49 per hour. The anticipated base salary range reflects the company’s good-faith estimate at the time of posting. Actual compensation will be determined based on experience, skills, qualifications, geographic location, internal equity, and business needs.