Transitional Care Management (TCM)

• Timely outreach to patients post-discharge, conducting clinical assessments, addressing barriers to recovery, and assisting in care transitions from inpatient, SNF, or ED back to primary care.
• Complete medication reconciliation, patient/caregiver education, and timely scheduling of follow-up appointments.
• Document TCM interactions in the electronic health record according to ACO and CMS standards.

Pharmacy Services

• Collaborate with network pharmacist to complete medication reviews and support adherence and optimization for patients with polypharmacy or chronic disease.
• Identify and escalate medication-related safety concerns to pharmacy services.
• Deliver patient education regarding medication changes, side effects, and therapy goals.

Controlled Substance Stewardship

• Participate in the implementation of network-wide controlled substance monitoring protocols, collaborating with providers to ensure compliance and safety.
• Review patient histories for risk, support utilization of prescription drug monitoring programs, and provide education on safe use, storage, and disposal.

Population Health & Performance Improvement

• Engage in network quality initiatives aimed at reducing readmissions, improving medication adherence, and enhancing patient outcomes.
• Use data analytics to identify at-risk patients and develop targeted outreach strategies.
• Participate in cross-functional meetings to drive operational improvements.

Core Competencies

• Patient centered communication and coordination.
• Strong communication and patient education skills.
• Proactive problem-solving and time management.
• Data review and documentation accuracy.
• Demonstrate flexibility/adaptability in a team based environment.
• Commitment to patient safety, satisfaction, and value-driven care.

Other Responsibilities

• Centralized remote role with regular phone/electronic outreach, EHR review, and virtual team meetings.
• Performs all other duties as assigned by the supervisor and/or designee

Education & Experience

• Registered Nurse (RN) with active state licensure; BSN preferred.
• Minimum of 3 years’ experience in primary care, case management, or population health settings.
• Skilled in telephonic and virtual patient communication, clinical assessment, and coordination across settings.
• Proficient in using EHRs, and population health analytics tools.
• Familiarity with CMS Care Coordination Services standards and guidelines.
• Ability to collaborate effectively communicate across multidisciplinary and multisite teams.