Transitional Care Manager

Home Recovery Home Aid • Richmond, VA

4d

About The Position

Home Recovery Home Aid is seeking a compassionate and driven Transitional Care Manager to coordinate safe, timely transitions from acute and post-acute settings—including hospitals, skilled nursing facilities, and rehabilitation facilities—to home health services. The role connects clinical teams, referral sources, and payers to help reduce readmissions, support continuity of care, and improve the patient and family experience during a high-risk period. The manager works with hospital case management, physicians, referral liaisons, and the home health interdisciplinary team to address gaps in care coordination across the Central Virginia service area.

Requirements

• Active RN license in good standing in the Commonwealth of Virginia.
• At least 2–3 years of clinical experience in home health, hospice, case management, or acute care discharge planning.
• Working knowledge of Medicare home health Conditions of Participation and transitional care models, such as BOOST, RED, or the Coleman Model.
• Strong understanding of readmission risk factors and evidence-based interventions.
• Excellent communication and relationship-building skills across clinical, administrative, and referral stakeholders.
• Proficiency with EMR and home health documentation systems, such as WellSky.
• Valid driver's license and reliable transportation for local travel between facilities and patient homes.

Nice To Haves

• Case Management Certification (CCM) or Certified Transitional Care Professional credential.
• Experience working directly with hospital case management departments in the Richmond/Central Virginia market.
• Familiarity with value-based care arrangements, bundled payments, or ACO referral pathways.
• Bachelor's degree in Nursing (BSN).

Responsibilities

• Manage patient transitions from hospital or skilled nursing facility discharge through home health start of care, ensuring timely intake, documentation, and clinical handoff.
• Coordinate discharge planning with hospital case managers, discharge planners, and physicians to identify appropriate candidates for home health services.
• Conduct in-person or telephonic transitional care assessments to identify medication discrepancies, follow-up appointment needs, and readmission risk factors.
• Monitor high-risk patients during the 30-day post-discharge period and coordinate interventions to prevent avoidable hospitalizations.
• Liaise among referral sources, payers, and the home health clinical team to resolve authorization, eligibility, or care-plan barriers.
• Track and report readmission rates, transition timeliness, and other key quality metrics.
• Support compliance with CMS Conditions of Participation related to care coordination and transitions of care.
• Collaborate with the intake and referral team to reduce the time from referral to start of care.
• Educate patients and caregivers on care plans, medication management, and warning signs requiring escalation.
• Build and maintain relationships with hospital systems, skilled nursing facilities, physician groups, and ACOs across the Central Virginia service area.

Benefits

• Competitive pay
• Paid weekly
• Medical, dental, vision, and life insurance
• Paid holidays and PTO
• 401(k) match
• Employee Assistance Program, including up to six free counseling sessions per year
• Career growth opportunities
• Collaborative work environment

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed