Transitional Care Management Registered Nurse

Certification / Registration / License

• Active, unrestricted Registered Nurse (RN) license.

Work Experience

• Minimum of five years of clinical nursing experience in acute care, discharge planning, post‑acute care, or transitional care.
• Minimum of three years of experience providing care and patient education to complex populations, including heart failure, COPD, GI bleed, sepsis, or stroke.

Knowledge / Skills / Abilities

• Advanced clinical expertise in complex patient management and transitional care.
• Strong care coordination, critical thinking, and clinical decision‑making skills.
• Demonstrated leadership in interdisciplinary collaboration and patient advocacy.
• Strong communication skills, including use of motivational interviewing techniques.
• Proficiency with electronic health records, care coordination tools, and telehealth platforms.
• Knowledge of regulatory requirements and reimbursement criteria related to transitional care.
• Strong organizational, analytical, and prioritization skills.
• Commitment to ethical practice, patient‑centered care, and continuous professional development.

Physical Requirements and Working Conditions

• Primarily remote work environment with occasional on‑site meetings.
• Standard schedule is Saturday, Sunday 0800-1830.

Preferred Job Requirements

Education

• Master of Science in Nursing or related field preferred.

Certification / Registration / License

• Preferred certifications include Medical‑Surgical RN (MEDSURG‑BC), Cardiac‑Vascular Nursing (CV‑BC), or Nursing Case Management (CMGT‑BC).

Experience

• Additional experience in transitional care or case management preferred.

Knowledge / Skills / Abilities

• Not required beyond minimum qualifications.

All responsibilities and requirements are subject to possible modification to reasonably accommodate individuals with disabilities. This job description does not state or imply that these are the only duties to be performed. Employees may be required to perform other job‑related duties as requested.

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