Transitional Care Management Nurse Practitioner

The Transitional Care Management (TCM) Nurse/Coordinator plays a key role in ensuring continuity of care for patients transitioning from an inpatient facility (hospital, SNF, rehab, etc.) to the home or outpatient setting. This position focuses on reducing readmissions, supporting safe transitions, improving patient outcomes, and enhancing the overall patient experience.

The TCM Nurse/Coordinator is responsible for ensuring continuity of care for patients transitioning from an inpatient facility to the home or outpatient setting.

• Initiate contact with patients within 2 business days of hospital discharge to perform post-discharge assessment.
• Provide telephonic or in-person follow-up care coordination within 14 days of discharge per CMS guidelines.
• Collaborate with physicians, nursing staff, social workers, and other healthcare providers to develop and implement post-discharge care plans.
• Ensure timely scheduling of follow-up appointments, medication reconciliation, and access to necessary home care or equipment.
• Educate patients and caregivers about diagnosis, medication regimen, follow-up appointments, and signs of complications.
• Monitor patients for signs of potential readmission and intervene early as needed.
• Document TCM activities according to regulatory standards and billing requirements.
• Track outcomes, including readmission rates and patient compliance.
• Identify gaps in care and work with multidisciplinary teams to improve transitional processes.

• Must be a U.S. citizen or hold an appropriate Visa to apply.
• Must be eligible for or hold an unrestricted license in the state you choose to practice in.
• WA (Washington)
• Possess or be eligible for a DEA license, NPI number, and have prescriptive authority.
• Board eligible/certified by the time of employment.
• Must be eligible to participate in Medicare/Medicaid programs.
• Certification in Case Management or Care Coordination required.

• Full Time, Monday-Friday
• Flexible Schedule
• Primarily remote setting with some patient home or clinic visits.
• Requires sitting, standing, and walking.
• May involve travel to various facilities or patient homes (if applicable).

• Strong clinical assessment and critical thinking skills.
• Knowledge of community resources, healthcare delivery systems, and transitional care best practices.
• Excellent communication, organizational, and interpersonal skills.
• EMR proficiency and accurate documentation skills.
• Ability to work independently and as part of a multidisciplinary team.

• Must have graduated from an approved ARNP program.
• Experience in primary care, hospital, or skilled nursing home or equivalent preferred, but new graduates from ARNP program are encouraged to apply.

We are an Equal Opportunity Employer and are committed to providing a workplace free from discrimination and harassment. Employment decisions are made without regard to race, color, religion, sex, sexual orientation, gender identity or expression, national origin, age, disability, genetic information, veteran status, or any other protected status under applicable federal, state, or local laws.

We comply with all applicable employment laws and regulations, including those related to laboratory safety, licensure, and credentialing.