RN Care Manager, Care Transitions

Role Overview Avail Health is launching a hospital-based Care Transitions Program supporting Medicare patients with complex medical, behavioral health, and social needs following discharge. The RN Care Manager leads the medical track of that program — serving as the primary clinical point of contact for assigned patients throughout the 30‑day TCM episode. Day-to‑day you’ll conduct post‑discharge outreach, perform clinical assessments, complete medication reconciliation, prepare pre‑visit summaries for the NP’s TCM encounter, and coordinate the referrals and services that keep high‑risk patients from bouncing back. You’ll work closely with the SW Care Manager, who leads the behavioral health track, collaborating cross‑functionally when medical and BH complexity overlap. Most of your work is virtual, with in‑person visits when patients require assessment that can’t be done via telehealth. This is a founding team role. You’ll help operationalize workflows, shape clinical protocols, and build a model designed to scale. What You’ll Own Post‑discharge outreach and ongoing clinical contact for assigned medical‑track patients throughout the 30‑day TCM episode Medication reconciliation and clinical assessment prior to the NP’s TCM encounter Pre‑visit chart preparation and clinical synthesis for the NP visit What You’ll Do Conduct post‑discharge outreach within CMS TCM timelines; perform tuck‑in calls for high‑risk patients to validate discharge plan adherence and identify early barriers to safe transition Assess patient condition, symptom burden, functional status, medication adherence, fall risk, and social barriers across the TCM episode Complete medication reconciliation and coordinate resolution of discrepancies with the NP Perform pre‑visit chart prep: review discharge summaries, HIE data, and medical records to identify clinical risks and gaps prior to the NP’s TCM encounter Coordinate referrals, follow‑up appointments, home services, and community resources to support safe transitions Conduct in‑person visits when patients require licensed assessment that cannot be completed virtually Collaborate daily with the NP, SW Care Manager, and Care Coordinator in team huddles; present clinical priorities using SBAR and contribute to risk stratification Consult with the SW Care Manager on psychosocial and BH barriers for medical‑track patients; provide clinical input to the SW for BH‑panel patients with medical complexity Maintain timely, accurate documentation in compliance with TCM billing requirements and CMS guidelines What Success Looks Like Post‑discharge outreach completed within CMS TCM timelines for 100% of assigned medical‑track patients Medication reconciliation completed and discrepancies resolved prior to every NP TCM visit Pre‑visit clinical summaries complete and available to the NP before every scheduled encounter 30‑day readmission rate for the assigned medical‑track panel at or below program benchmarks Referrals, follow‑up services, and care plan coordination completed without gaps across the patient panel What You Bring Required: ADN or BSN from an accredited program; BSN strongly preferred Active, unrestricted Maryland RN license in good standing 3+ years of clinical RN experience with direct responsibility for transitions of care, TCM, hospital discharge planning, post‑acute care coordination, or readmission reduction Experience in mobile care delivery (home health, hospice, or house call settings) with medically complex adult or geriatric populations Strong clinical assessment, medication reconciliation, escalation, and interdisciplinary care coordination skills Familiarity with CMS TCM requirements and documentation standards Valid driver’s license, reliable transportation, and active automobile insurance Reliable high‑speed internet and a dedicated, HIPAA‑compliant home workspace Preferred: Experience in longitudinal care management, complex case management, behavioral health care coordination, or population health for high‑risk Medicare populations Familiarity with telehealth platforms, HIE systems, or ambient AI documentation tools Experience in an early‑stage or startup‑style healthcare environment with evolving workflows Schedule and Work Style Work Type: Hybrid — primarily remote with in‑person visits when clinically indicated Schedule: Monday–Friday, 8:00 AM – 5:00 PM ET; occasional on‑call as program scales Travel: Field visits across Montgomery County, MD; must reside within commuting distance of Rockville Autonomy: High clinical independence with daily interdisciplinary team touchpoints Compensation and Perks Salary Range: $94,000 – $115,000 annually, commensurate with experience Key Benefits: Medical, dental, and vision insurance HSA | 401(k) with employer match 15 days PTO | 8 + 1 floating holidays Professional liability and malpractice insurance provided All devices for clinical and technology‑related activities provided About Avail Health Avail Health is a Nurse Practitioner–founded organization delivering mobile and virtual care to Medicare‑age patients. We combine technology, operational rigor, and clinical excellence to improve outcomes for complex populations. For more visit #J-18808-Ljbffr Vail Health