Senior Manager, RN, Care Transitions

Avail Health•Rockville, MD

17h•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 Senior Manager, RN is the frontline clinical leader of that program — the primary on-site representative of Avail Health within the hospital and the day-to-day leader of the interdisciplinary Care Transitions team. You’ll work on the hospital floor identifying eligible patients, conducting assessments, supporting enrollment, and building the working relationships with hospital care management teams that make the program run. You’ll lead daily virtual huddles with the remote team — NP, RN Care Manager, SW Care Manager, and Care Coordinators — managing panel priorities, escalations, and coordination workflows. You’ll provide direct people management and clinical oversight for the team, and partner closely with the Senior Operations Manager and executive leadership on program performance and growth. This is a founding leadership role. You’re not inheriting a built program — you’re standing one up.

Requirements

Active, unrestricted Maryland RN license in good standing; current BLS certification
5+ years of clinical RN experience including mobile care delivery (home health, hospice, or house calls) and post-hospital transitions, discharge planning, or complex care coordination for high-risk populations
2+ years of experience supervising, coordinating, or leading clinical staff or interdisciplinary care teams in a fast-paced healthcare environment
Demonstrated ability to rapidly assess and prioritize complex clinical, behavioral health, psychosocial, and environmental risk factors impacting safe transitions
Strong relationship-building skills with hospital stakeholders, patients, caregivers, and interdisciplinary teams
Excellent organizational and time management skills with ability to manage competing priorities in a startup-style environment

Nice To Haves

Experience in hospital care management, discharge planning, TCM, or readmission reduction programs
ED, observation, rapid assessment, triage, or other high-acuity care coordination experience strongly preferred
Experience with Medicare-aged populations with complex medical, behavioral health, or psychosocial needs
Experience supporting clinical operations, program implementation, or startup launches in partnership with operational or executive leadership

Responsibilities

Day-to-day clinical leadership and people management of the interdisciplinary Care Transitions team
Hospital-side patient identification, assessment, enrollment, and warm handoff workflows
Hospital partnership relationships and Avail Health’s on-site presence and reputation
Serve as the primary on-site Avail Health representative within the hospital — participating in huddles, rounds, and discharge planning discussions to identify eligible patients
Engage patients and caregivers directly in the hospital to conduct assessments, support program enrollment, and coordinate transition planning
Apply advanced clinical judgment to rapidly assess medical, behavioral health, psychosocial, and environmental risk factors; risk-stratify patients and mobilize the right interdisciplinary resources
Lead daily virtual huddles with the remote Care Transitions team; manage panel priorities, escalations, and cross-team coordination
Provide direct people management, coaching, and clinical oversight for assigned team members
Partner with the Senior Operations Manager on workflow implementation, operational readiness, quality monitoring, and program development
Conduct occasional mobile in-person visits post-discharge; provide coverage and clinical support for team RNs as needed
Partner with executive leadership on program performance, hospital partnership strategy, and scaling initiatives