Transitional Care Management Registered Nurse

Department: 39733 Enterprise Corporate - NC/GA Transitional Care Management Status: Part time Benefits Eligible: Yes Hou rs Per Week: 20 Schedule Details/Additional Information: Fully remote work from home position Saturday & Sunday 0800-1830 with Potential to include holidays. Must have High Speed Internet. Must live in NC within one hour of Mint Hill Pay Range: $38.20 - $57.30 MUST LIVE IN NC WITHIN ONE HOUR OF MINT HILL. Major Responsibilities Conduct comprehensive clinical assessments of high‑risk patients at discharge and throughout the 30‑day transitional care period, identifying medical, psychosocial, and environmental risk factors.

Develop, implement, and continuously update individualized, patient‑centered care plans addressing clinical needs, medication management, and follow‑up care. Coordinate care and facilitate timely communication among inpatient providers, primary care, specialists, home health agencies, and community resources. Serve as the primary point of contact for patients and families, providing education on disease management, medications, symptom monitoring, and escalation protocols. Manage a caseload of post‑discharge patients and ensure completion of follow‑up appointments, home visits, and adherence to prescribed treatments.

Lead and participate in interdisciplinary rounds and case conferences, collaborating with physicians, pharmacists, social workers, behavioral health providers, and nursing staff. Monitor patient progress through outreach visits, telehealth, and phone contacts, intervening promptly when clinical or psychosocial issues arise. Ensure compliance with CMS Transitional Care Management guidelines, Joint Commission standards, and organizational policies through accurate and timely documentation. Participate in quality improvement initiatives and identify opportunities to strengthen transitional care workflows and patient outcomes. Perform other duties and responsibilities as assigned.

Education

Bachelor of Science in Nursing (BSN) required. 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…

Read the full posting