Acute Care & Transitions Manager (RN or LPN)

TGH Senior Center Powered by Greenbrook Medical•Tampa, FL

2d•$100,000•Hybrid

About The Position

The Acute Care & Transitions Manager will own the day-to-day coordination of patients moving through acute care settings, from hospital and emergency department admission through SNF stays and successful transition back into the community. This role involves monitoring acute care utilization, building relationships with hospital and SNF partners, coordinating discharge plans, and ensuring patients are connected back to their Greenbrook care team quickly and safely. The position is highly proactive and time-sensitive, ensuring Greenbrook is aware of patient hospitalizations, understands the situation, communicates with the care team, and plans for next steps. The manager will also serve as a clinical resource for urgent patient needs and help prevent unnecessary ED utilization by ensuring patients have appropriate access to care. This role requires close collaboration with Greenbrook physicians, Complex Case Managers, center managers, medical assistants, hospitalists, inpatient care managers, skilled nursing facilities, and specialists. The position reports to the VP, Market Medical Director and works alongside the broader care management team. Travel between clinics, hospitals, and skilled nursing facilities is required.

Requirements

Active RN or LPN license.
3+ years of nursing, acute care, care management, or transitions of care experience.
Experience working with hospitals, emergency departments, skilled nursing facilities, or inpatient care teams.
Strong clinical judgment and patient triage skills.
Experience with transitions of care, discharge planning, or post-acute care coordination.
Experience in managed care, Medicare Advantage, or value-based primary care.
Strong organizational skills and ability to manage multiple time-sensitive patients and priorities.
Strong Excel skills and comfort using data to identify trends and opportunities.
A mindset grounded in our core values of Heart, Excellence, Accountability, Resilience, and Teamwork.

Nice To Haves

Experience in hospital case management, utilization management, or transitions of care.
Experience working directly with hospitalists, inpatient care managers, or SNFs.
Experience supporting Medicare Advantage populations.
Knowledge of local hospitals, SNFs, specialists, and community resources.
Experience reducing avoidable ED visits, hospitalizations, or readmissions.
Thrive in fast-paced environments where priorities change quickly.
Exceptionally organized, proactive, and known for following through.
Build trust quickly with physicians, nurses, hospital teams, patients, and external partners.
Comfortable working independently and traveling throughout the market.
Bilingual in Spanish.

Responsibilities

Monitor hospital and emergency department admissions daily and proactively identify Greenbrook patients requiring intervention.
Establish timely communication with hospitalists, inpatient care managers, and other members of the acute care team.
Understand the reason for admission, clinical status, anticipated discharge needs, and barriers to a safe transition.
Coordinate discharge planning and ensure appropriate follow-up is scheduled with the Greenbrook care team.
Complete or coordinate timely post-discharge outreach and medication reconciliation.
Ensure critical discharge information, medications, follow-up needs, and care plans are communicated to the appropriate Greenbrook team members.
Identify patients requiring additional support and transition them to the Complex Case Manager or other appropriate resources.
Monitor Greenbrook patients admitted to skilled nursing facilities.
Establish relationships with SNF clinical teams and maintain visibility into patient progress.
Track anticipated discharge dates and proactively address barriers that may unnecessarily extend SNF stays.
Coordinate the patient's transition from SNF back to the Greenbrook clinic and community.
Ensure follow-up appointments, medication reconciliation, and other post-discharge needs are completed promptly.
Escalate complex or high-risk patients to the Complex Case Manager for ongoing longitudinal management.
Serve as a clinical resource for patient triage and urgent needs.
Evaluate incoming patient concerns and guide patients toward the most appropriate level of care.
Support same-day access and Greenbrook's ER diversion protocols.
Coordinate with clinic teams and physicians to identify alternatives to unnecessary ED utilization.
Perform IV placement in the clinic when clinically appropriate and within scope.
Identify recurring acute care utilization patterns and share insights with physicians and care management leadership.
Develop trusted relationships with hospitalists, inpatient care managers, SNF clinical teams, specialists, and other external care partners.
Establish reliable communication pathways with hospitals and SNFs throughout your market.
Represent Greenbrook as a proactive and collaborative clinical partner.
Identify opportunities to improve communication, discharge planning, and transitions between Greenbrook and external facilities.
Help develop and improve Greenbrook's systems and workflows for managing acute care events and transitions.
Track patients through the acute care journey from admission through return to the community.
Maintain visibility into outstanding discharge and follow-up needs.
Use data to identify trends in hospitalizations, ED utilization, readmissions, and SNF utilization.
Identify breakdowns in transition workflows and recommend improvements.
Ensure no critical post-discharge action falls through the cracks.