Position Objective:

The Manager of Transitional Care and Telehealth Services is responsible for the strategic development, implementation, and daily oversight of programs that ensure seamless, high-quality, and cost-effective patient transitions across various healthcare settings (e.g., hospital to home, skilled nursing facility, or other community settings). This role integrates virtual care (telehealth/telemedicine, remote patient monitoring) methodologies into the transitional care processes to support continuous patient monitoring, education, and support remotely. The manager leads a multidisciplinary team, drives quality improvement initiatives, ensures regulatory compliance, and improves overall patient outcomes and satisfaction while reducing avoidable readmissions. 

Essential Duties and Responsibilities

1)       Program Development & Oversight: Develop, implement, and manage comprehensive transitional care and virtual health programs, including program goals, policies, and workflows.

2)       Care Coordination: Oversee the coordination of patient care across the continuum, ensuring effective communication and warm handoffs between physicians, nurses, social workers, external providers, and community resources.

3)       Telehealth Integration: Spearhead the integration of virtual technologies (video conferencing, secure messaging, remote patient monitoring devices) to support patient engagement, chronic disease management, and remote follow-up care during transitions.

4)       Staff Management & Leadership: Provide leadership, mentorship, and supervision to a team of care coordinators, social workers, and telehealth staff. Assist in recruitment, training, and performance management.

5)       Patient Advocacy & Education: Ensure patient-centered care models are utilized. Oversee staff in educating patients and their families about care plans, medications, and self-management strategies to empower them in their care.

6)       Quality Improvement & Compliance: Monitor key performance indicators (KPIs) such as readmission rates, length of stay, and patient satisfaction. Utilize data analysis to identify areas for improvement and ensure adherence to all regulatory standards (CMS, NCQA, state-specific requirements).

7)       Documentation & Systems: Ensure accurate and real-time documentation within the Electronic Health Record (EHR) and care management systems. Collaborate with IT to optimize systems for information sharing across entities. 

Required Qualifications and Skills

• Education: Bachelor’s degree in nursing, Social Work, Healthcare Administration, or a related field. A Master's degree is preferred.
• Experience:
• Minimum of 3-5 years of clinical or case management experience in a healthcare setting (acute care, home health, etc.).
• Minimum of 2 years of supervisory or management experience in a relevant field.
• Experience with telehealth platforms, remote patient monitoring, and EHR systems is essential.
• Licensure/Certification: Current active licensure as a Registered Nurse (RN), Licensed Clinical Social Worker (LCSW), or Licensed Clinical Professional Counselor (LCPC) in the state of practice. Certification in Case Management (CCM) or Transitional Care Management (TCM) is highly valued.
• Required Knowledge and Skills:
• Exceptional communication, interpersonal, and problem-solving skills.
• Strong analytical and data management abilities to drive performance improvement.
• Knowledge of quality improvement approaches and healthcare regulations.
• Ability to work collaboratively with multidisciplinary teams and external partners

Working Conditions, Equipment, Physical Demands:

There is a reasonable expectation that employees in this position will be exposed to blood-borne pathogens.

Physical Demands -

The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.

The above job description is an overview of the functions and requirements for this position.  This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.