RN Complex Care Coordinator - Transitional Care Management (TCM)

ProHealth Care • Waukesha, WI

31d • Hybrid

About The Position

Begin your story with ProHealth Care. We offer a warm, collaborative culture and a team of professionals dedicated to exceptional patient care across the care continuum. This role is part of our Complex Care Management program and plays a vital part in supporting high-risk patients as they transition from the hospital to home. The Transitional Care Management RN is the first point of connection with recently discharged patients, ensuring a safe, well-coordinated transition home. This is a high-acuity, fast-paced phone-based nursing role, ideal for an RN who thrives in rapid prioritization, independent critical thinking, and complex problem solving. Provide post-discharge Transitional Care Management (TCM) support through timely outreach calls to recently discharged patients. Complete full medication reconciliation, reinforce the discharge plan, assess symptoms, identify safety issues, and coordinate urgently with pharmacies, providers, and specialists. Manage 10-12 complex calls daily with multiple tasks between calls. Address time-sensitive concerns (e.g., incorrect meds, missing refills, anticoagulation issues) and escalate when needed. Document all assessments and interventions in Epic. Collaborate across the care team to ensure safe transitions, reduce readmissions, and support patient self-management. Hybrid work available after completing onsite orientation ( this position will work onsite and remotely)

Responsibilities

• Complete structured TCM outreach calls, with 10-12 calls daily
• Perform full medication reconciliation and triage clinical concerns
• Coordinate urgently with pharmacies, providers, and specialists
• Manage high-complexity patients (heart failure, COPD, anticoagulation, chronic disease instability, social barriers, etc.)
• Address time-sensitive issues e.g., medications, follow up care coordination, ect.
• Submit safety reports and escalate concerns in real time
• Document thoroughly in Epic and close care gaps
• Collaborate with inpatient and ambulatory teams to ensure a smooth transition
• Provide post-discharge Transitional Care Management (TCM) support through timely outreach calls to recently discharged patients.
• Complete full medication reconciliation, reinforce the discharge plan, assess symptoms, identify safety issues, and coordinate urgently with pharmacies, providers, and specialists.
• Manage 10-12 complex calls daily with multiple tasks between calls.
• Address time-sensitive concerns (e.g., incorrect meds, missing refills, anticoagulation issues) and escalate when needed.
• Document all assessments and interventions in Epic.
• Collaborate across the care team to ensure safe transitions, reduce readmissions, and support patient self-management.

Benefits

• Engaging and community focused culture
• Competitive Salaries
• Opportunity for professional career growth
• Robust benefits for full-time and regular part-time roles, including Generous PTO
• Choices in insurance
• HSA
• Tuition reimbursement
• immediate 401K match
• discounted tickets to various entertainment, social, and sporting events

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Ambulatory Health Care Services
• Education Level: No Education Listed
• Number of Employees: 1,001-5,000 employees