Program Director, Transitional Care

Job Summary:

The Program Director, Transitional Care Management (TCM) is responsible for the operational, clinical, and programmatic leadership of the centralized Hospital-to-Home Transitional Care Management, Remote Patient Monitoring (RPM), and post-discharge appointment coordination programs. The Program Director oversees telehealth transitional care workflows, Monitoring Specialists, Patient Screening Navigators, and related program staff to support post-discharge outreach, follow-up care, remote monitoring, escalation workflows, and timely appointment scheduling.

The Program Director leads workflow standardization, staff training, KPI monitoring, reporting, and continuous improvement efforts to reduce preventable emergency visits and 30-day readmissions. This position reports to the VP, Associate Chief Logistics Officer and collaborates with clinical, operational, IT/Telehealth, informatics, rural hospital, case management, ambulatory practice, and community partners to sustain a scalable virtual transitional care program.

• Provide operational and clinical leadership for the centralized TCM/RPM program, ensuring consistent program operations, timely follow-up, standardized care coordination, and safe transitions for enrolled patients within the leader’s applicable professional scope of practice.
• Establish and oversee patient identification, eligibility review, enrollment prioritization, and risk stratification processes to appropriately target high-risk post-discharge patients.
• Oversee the Hospital-to-Home transitional care model, including post-discharge outreach, telehealth follow-up visits, transition-period monitoring, patient/caregiver education, and closed-loop communication with community providers.
• Provide direct or matrixed supervision of assigned clinical and non-clinical program staff, which may include APPs, nurses, physicians, monitoring specialists, patient screening navigators, and related team members, including recruitment, onboarding, competency validation, education, and performance support.
• Develop, maintain, and operationalize TCM/RPM protocols, outreach scripts, medication reconciliation checklists, telehealth documentation standards, escalation pathways, workflow tools, and staff training materials.
• Build and maintain relationships with ambulatory practices, community providers, rural network hospitals, skilled nursing facilities, home health agencies, EMS partners, county public health departments, and community-based organizations to support timely follow-up and smooth care transitions.
• Partner with IT/Telehealth, clinical informatics, and vendor teams to support telehealth platform configuration, scheduling workflows, documentation workflows, data capture, RPM workflows, and community provider coordination processes.
• Maintain operational readiness for RPM and virtual care services, including monitoring workflow design, clinical scenario review, escalation threshold refinement, readiness validation, and outpatient deployment support.
• Lead outcome monitoring, performance improvement, and corrective action activities related to enrollment, outreach completion, telehealth visit completion, medication reconciliation, RPM adherence, escalation timeliness, care gap closure, patient engagement, avoidable utilization, and 30-day readmission reduction.
• Prepare routine performance updates for program governance, leadership review, funder reporting, and continuous improvement planning.
• Collaborate with the Office of Research and Grants Administration on grant deliverables, narrative updates, voucher support, expenditure documentation, and compliance with program requirements.
• Ensure program workflows align with patient safety expectations, regulatory…