Transitional Care Manager

Overview

We are seeking a compassionate and driven Transitional Care Manager to join our team!In this role, you will be responsible for coordinating safe, timely transitions of patients from acute and post-acute settings (hospitals, SNFs, rehab facilities) into home health services. This role bridges clinical, referral source, and payer relationships to reduce readmissions, ensure continuity of care, and improve the patient and family experience during a high-risk period of the care continuum. The TCM works closely with hospital case management, physicians, referral liaisons, and the home health interdisciplinary team to close gaps in care coordination.

If you’re passionate about relationship building, have a talent for outreach, and want to make a difference in people’s lives, we’d love to hear from you!

What We Offer*:

We know that, to be the best place for our patients, we must be the best place to work for our employees.  We offer the following to our employees:

• Competitive pay
• Paid on a weekly basis
• Medical/dental/vision/life insurance
• Paid holidays/PTO/401(k) match
• Employee Assistance Program (EAP) including up to 6 free counseling sessions/year
• Career growth opportunities
• Great and collaborative work environment

Responsibilities

• Manage patient transitions from hospital/SNF discharge through home health start of care, ensuring timely intake, documentation, and clinical handoff
• Conduct discharge planning coordination with hospital case managers, discharge planners, and physicians to identify appropriate candidates for home health services
• Perform transitional care assessments (in-person or telephonic) to identify medication discrepancies, follow-up appointment needs, and risk factors for readmission
• Monitor high-risk patients during the 30-day post-discharge window and coordinate interventions to prevent avoidable hospitalizations
• Serve as a liaison between referral sources, payers, and the home health clinical team to resolve authorization, eligibility, or care-plan barriers
• Track and report readmission rates, transition timeliness, and other key quality metrics
• Support compliance with CMS Conditions of Participation related to care coordination and transitions of care
• Collaborate with the intake/referral team to reduce time from referral to start of care
• Educate patients and caregivers on care plans, medication management, and warning signs requiring escalation
• Build and maintain relationships with hospital systems, SNFs, physician groups, and ACOs across the Central Virginia service area

Qualifications

• Required:

  • RN license, active and in good standing in the Commonwealth of Virginia
  • Minimum 2-3 years of clinical experience in home health, hospice, case management, or acute care discharge planning
  • Working knowledge of Medicare home health Conditions of Participation and transitional care models (e.g., BOOST, RED, Coleman Model)
  • Strong understanding of readmission risk factors and evidence-based interventions
  • Excellent communication and relationship-building skills across clinical, administrative, and referral stakeholders
  • Proficiency with EMR/home health documentation systems (e.g., WellSky)
  • Valid driver's license and reliable transportation for local travel between facilities and patient homes

  Preferred:

  • Case Management Certification (CCM) or Certified Transitional Care Professional credential
  • Experience working directly with hospital case management departments in the Richmond/Central Virginia market
  • Familiarity with value-based care arrangements, bundled payments, or ACO referral pathways
  • Bachelor's degree in Nursing (BSN)

*Eligibility for certain benefits may depend on employment status

Home Recovery Home Aid is an equal opportunity employer committed to providing equal employment opportunities without regard to race, color, religion, sex (including pregnancy), sexual orientation, age, national origin, disability, genetic information, veteran status, or any other classification protected by applicable law.