CHRONIC CARE & TRANSITIONAL CARE NURSE

Job Summary:

The Chronic Care & Transitional Care Management Nurse plays a critical role in identifying, supporting, and coordinating care for high-risk, chronically ill patients, including those receiving palliative care services. This role serves as a trusted, patient-friendly voice of reassurance-helping patients, caregivers, and providers navigate the complexities and early uncertainties following inpatient discharge.

The CCM/TCM Nurse supports value-based care initiatives by leading care coordination, transitional care outreach, medication reconciliation, quality metric monitoring, and care gap closure, while partnering closely with providers, clinical staff, hospitals, and payers.

Key Responsibilities:

Chronic Care Management (CCM)

• Identify and proactively support high-risk, chronically ill patients through ongoing care coordination and outreach
• Support patients receiving palliative care by facilitating care navigation, education, and communication across care teams
• Assist providers in developing, implementing, and updating individualized patient care plans
• Perform medication reconciliation and ensure medication accuracy across care settings
• Conduct mass patient communications (calls, messages, letters) related to care management, quality initiatives, and care reminders
• Monitor quality metrics and care gaps; assess patient quality measure status and initiate outreach to support closure
• Participate in quality improvement activities to improve outcomes and performance across value-based care programs
• Provide care navigation support, connecting patients to appropriate clinical, community, and post-acute resources

Transitional Care Management (TCM)

• Review daily inpatient discharge reports and payer ADT alerts to identify eligible patients
• Conduct patient outreach within 48 hours of inpatient discharge to assess needs, reinforce discharge instructions, and identify barriers to recovery
• Coordinate with providers, clinical staff, hospitals, and post-acute facilities to support safe transitions of care
• Maintain working knowledge of inpatient discharge processes, medication reconciliation, and post-discharge follow-up requirements
• Utilize hospital EMRs, payer data, ADT alerts, EMR tasks, and other discharge reporting tools to identify and outreach to patients

Collaboration & Operations

• Support providers and clinical teams with patient coordination, documentation, and follow-up needs
• Participate in staff meetings, case conferences, and interdisciplinary care discussions
• Document patient interactions, care plans, and outreach activities accurately and timely in the EMR

• Support all value-based care programs as needed, including quality, risk, and utilization management initiatives

Qualifications:

• Active RN or LPN licensure (RN preferred)
• Minimum of 3-5 years of clinical experience as an RN or LPN
• Strong communication skills with a compassionate, patient-centered approach

Preferred:

• Experience in primary care settings
• Knowledge of discharge planning and transitional care processes
• Experience with palliative care, chronic care management, or post-acute care
• Familiarity with hospital EMRs, payer ADT alerts, and value-based care workflows

Ideal Candidate Profile

The ideal candidate is calm, empathetic, organized, and proactive-someone who can serve as a reassuring presence for patients and families during vulnerable transition periods. This nurse is comfortable navigating complexity, collaborating across teams, and supporting both patients and providers in a value-based care environment.

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
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