Senior Manager, RN - Care Transitions

Avail Health•Rockville, MD

2d•$110,000 - $126,500•Onsite

About The Position

About Avail Health Avail Health is a Nurse Practitioner–founded organization dedicated to removing barriers to care, access, and meaningful clinical work for Medicare-age individuals. We combine thoughtful technology, strong operational infrastructure, and deep respect for the patient–provider relationship to enable nurse-led virtual and mobile care models. As a fast-growing organization, we are building durable clinical infrastructure to support innovative care programs across multiple states, with a focus on improving outcomes for complex and underserved senior populations. Role Summary The Senior Manager, RN – Care Transitions is a frontline leadership role responsible for supporting the day-to-day execution of Avail Health’s Care Transitions Program in partnership with hospital teams and community stakeholders. This role serves as the primary on-site presence for Avail Health within the hospital environment, helping to identify eligible patients, coordinate transitions of care, and support patient engagement following hospital discharge. The Senior Manager will act as the local team leader for the care transitions team, supporting coordination of team activities and limited people management responsibilities while working closely with the senior leadership team, who maintain accountability for overall program strategy and clinical oversight. A central component of this role is building strong partnerships with hospital leadership and frontline teams, serving as the face of Avail Health for both hospital stakeholders and patients entering the program. The ideal candidate brings strong clinical assessment and critical thinking skills, particularly in evaluating patient risk and determining appropriate program engagement for complex Medicare-aged populations transitioning from hospital to home.

Requirements

Active, unrestricted Maryland Registered Nurse (RN) license in good standing.
Current Basic Life Support (BLS) certification.
Minimum 5+ years of clinical RN experience with some prior mobile nursing experience, providing care to patients where they reside.
Experience supporting post-hospital transitions of care, discharge planning, or complex care coordination.
Minimum 2+ years of experience supervising or coordinating clinical staff or care teams.
Strong clinical assessment and critical thinking skills managing complex patient populations.
Excellent interpersonal and communication skills with the ability to build strong relationships with hospital teams and patients.
Ability to operate effectively in a new program environment with evolving workflows and processes.

Nice To Haves

Experience in hospital care management or discharge planning environments, transitions of care (TOC), transitional care management (TCM) or hospital readmission reduction programs.
Emergency Department (ED) triage experience is highly preferred.
Experience delivering home-based care through home health, hospice, or mobile care programs.
Experience working with Medicare-aged populations with complex medical or behavioral health needs.
Experience supporting clinical workflows, program implementation, or new care model launches.

Responsibilities

Hospital Partnership & Customer Success Serve as the primary on-site representative of Avail Health within the hospital environment, building strong relationships with hospital leadership, care management teams, and frontline clinical staff.
Participate in hospital coordination activities including daily huddles, rounds, and care planning discussions to identify patients eligible for the Care Transitions Program.
Support effective collaboration and warm handoffs between hospital teams and Avail Health to ensure smooth transitions from hospital to home.
Represent Avail Health professionally and help ensure a positive partnership experience for hospital stakeholders.
Patient Identification & Program Enrollment Review hospital discharge lists and clinical documentation to identify patients eligible for the Care Transitions Program.
Conduct patient outreach, assessments, and enrollment discussions with eligible patients and caregivers.
Apply strong clinical judgment to assess patient complexity and risk factors, supporting appropriate prioritization and engagement within the program.
Coordinate with hospital teams to facilitate timely program enrollment and continuity of care following discharge.
Team Leadership & Program Execution Serve as the local team leader for the Care Transitions care team, helping coordinate day-to-day team activities and patient workflows.
Provide limited people management for clinical and community-based staff during the early stages of program launch.
Collaborate closely with the senior leadership team to support team operations, workflow management, and operational coordination.
Execute program workflows and care coordination processes established by leadership while providing frontline insights that help inform ongoing program improvement.
Care Coordination & Cross-Program Navigation Support coordination of care for patients transitioning from hospital to home across both medical and behavioral health populations.
Facilitate referrals into appropriate hospital programs, community resources, and Avail Health care programs when clinically appropriate.
Help ensure patients and caregivers understand and successfully navigate post-discharge care plans.
Technology & Program Infrastructure Utilize Avail Health’s technology platforms and tools to support patient identification, care coordination, and program tracking.
Partner with hospital teams to support adoption of program tools, including customized dashboards and reporting used to track program engagement and outcomes.
Serve as a knowledgeable frontline resource for hospital stakeholders using Avail technology platforms, helping address day-to-day questions and ensuring effective use of program tools.
Collaborate with Avail’s technology and operations teams to provide feedback that helps refine tools and workflows as the program evolves.