Transitional Care Case Manager

Department/Unit:
Care Management/Social Work

Work Shift:

Day (United States of America)
Salary Range: $94,957.00 - $

Under the guidance of the Case Management Manager and the Transitional Care Clinic Medical Director, the Transitional Care Case Manager (TCCM) facilitates and coordinates appropriate referrals to the TCC. The TCCM assists with managing the referral process, data collection, and ongoing coordination of patient care in the clinic. The TCCM further coordinates post‑discharge contacts with indicated patients outside the clinic structure for readmission avoidance.

The TCCM works with both internal and external stakeholders to achieve positive outcomes for assigned patients.

• Collaborate with internal providers, CM/SW teams and nursing to review TCC referrals.
• Evaluate patient eligibility against TCC accepting criteria.
• Act as a liaison between inpatient teams, the TCC and patients/families throughout the referral period to coordinate first post‑discharge appointments.
• Establish TCC appointments and ensure patient/caregiver agreement with timing and location.
• Work with patient/caregiver to secure transportation if needed.
• Ensure the appointment information is available on the AVS.
• Complete post‑discharge transitional care call within 72 hours.
• Complete necessary documentation in EHR.
• Coordinate with internal and external resources for any needs or concerns identified during post‑discharge contact.
• Document any updates to care plan in the EHR.
• Collaborate with the TCC Medical Director to complete and aggregate any data related to TCC patients, referrals, and ongoing care plans, including data for the VBE or grant fund.
• Collaborate in presenting ongoing data to internal and external stakeholders when indicated.
• Remain in communication with TCC providers to assist with any clinical intervention or patient care education.
• Implement interventions focused on readmission and ED diversion.
• Work with TCC team to ensure hand‑off to established or new primary care practice.
• Act as point of contact for CDPHP post‑discharge for TCC and other identified cases.
• Participate in clinical performance improvement activities focused on the goals of the TCC and VBE programs.
• Expand to non‑TCC patients for transition of care tasks based on caseload and as designated by the CM leadership and VBE leadership.
• Adhere to departmental and hospital regulatory requirements specific to CM role.
• Work with TCC team to monitor regulatory compliance in the clinic setting.
• Document in the EHR per departmental and hospital standards for discharge planning and any post‑acute discharge interventions.

• Registered Nurse (RN) – State Licensure and/or Compact State Licensure.
• At least a Bachelor’s Degree preferred; required upon hire.
• 4–6 years of nursing experience (min. 3 years in direct care nursing and/or case management).
• Recent experience in case management, utilization management, and/or discharge planning/home care in a high‑volume acute care hospital preferred.
• Ability to multi‑task and work autonomously while collaborating with inpatient and outpatient teams.
• Effective communication, facilitation, and organizational skills.
• Assertive and creative problem‑solving, critical thinking, systems planning, and patient care management.
• Self‑directed with adaptability to a changing environment.
• Basic knowledge of computer systems applicable to utilization review process.

Standing, walking, sitting, carrying, pushing, pulling, climbing, balancing, stooping, kneeling, crouching, crawling, reaching, handling, grasping, feeling, talking, hearing, repetitive motions, eye/hand/foot coordination, and constant status as described in the role.

Equal Opportunity Employer. The role may require access to sensitive information, which is protected in accordance with institutional policies and applicable laws.