RN Care Manager, Care Transitions

Avail Health•Rockville, MD

7h•Hybrid

About The Position

Avail Health is launching a hospital-based Care Transitions Program supporting Medicare patients with complex medical, behavioral health, and social needs following discharge. The RN Care Manager leads the medical track of that program — serving as the primary clinical point of contact for assigned patients throughout the 30-day TCM episode. Day-to-day you’ll conduct post-discharge outreach, perform clinical assessments, complete medication reconciliation, prepare pre-visit summaries for the NP’s TCM encounter, and coordinate the referrals and services that keep high-risk patients from bouncing back. You’ll work closely with the SW Care Manager, who leads the behavioral health track, collaborating cross-functionally when medical and BH complexity overlap. Most of your work is virtual, with in-person visits when patients require assessment that can’t be done via telehealth. This is a founding team role. You’ll help operationalize workflows, shape clinical protocols, and build a model designed to scale.

Requirements

ADN or BSN from an accredited program; BSN strongly preferred
Active, unrestricted Maryland RN license in good standing
3+ years of clinical RN experience with direct responsibility for transitions of care, TCM, hospital discharge planning, post-acute care coordination, or readmission reduction
Experience in mobile care delivery (home health, hospice, or house call settings) with medically complex adult or geriatric populations
Strong clinical assessment, medication reconciliation, escalation, and interdisciplinary care coordination skills
Familiarity with CMS TCM requirements and documentation standards
Valid driver’s license, reliable transportation, and active automobile insurance
Reliable high-speed internet and a dedicated, HIPAA-compliant home workspace

Nice To Haves

Experience in longitudinal care management, complex case management, behavioral health care coordination, or population health for high-risk Medicare populations
Familiarity with telehealth platforms, HIE systems, or ambient AI documentation tools
Experience in an early-stage or startup-style healthcare environment with evolving workflows

Responsibilities

Post-discharge outreach and ongoing clinical contact for assigned medical-track patients throughout the 30-day TCM episode
Medication reconciliation and clinical assessment prior to the NP’s TCM encounter
Pre-visit chart preparation and clinical synthesis for the NP visit
Conduct post-discharge outreach within CMS TCM timelines; perform tuck-in calls for high-risk patients to validate discharge plan adherence and identify early barriers to safe transition
Assess patient condition, symptom burden, functional status, medication adherence, fall risk, and social barriers across the TCM episode
Complete medication reconciliation and coordinate resolution of discrepancies with the NP
Perform pre-visit chart prep: review discharge summaries, HIE data, and medical records to identify clinical risks and gaps prior to the NP’s TCM encounter
Coordinate referrals, follow-up appointments, home services, and community resources to support safe transitions
Conduct in-person visits when patients require licensed assessment that cannot be completed virtually
Collaborate daily with the NP, SW Care Manager, and Care Coordinator in team huddles; present clinical priorities using SBAR and contribute to risk stratification
Consult with the SW Care Manager on psychosocial and BH barriers for medical-track patients; provide clinical input to the SW for BH-panel patients with medical complexity
Maintain timely, accurate documentation in compliance with TCM billing requirements and CMS guidelines