Transitional Care Manager (Compact RN license required) Job Listing at Emerus Holdings Inc. in Houston, TX (Job ID 2025-19837)

Description

The purpose of this position is to manage a patient's successful transition from hospital to home. The Transitional Care Manager is responsible for practicing in a high-quality, patient-centered, systematic, and evidence-based approach of assessment, diagnosis, planning, implementation and evaluation for all Emerus patients. As a member of the multidisciplinary health team, the Transitional Care Manager identifies high-risk, complex patients for program enrollment and communicates with all entities involved in the care of the patient to promote and maximize high-quality care coordination. The practice of this position has a direct impact on patient outcomes and Hospital performance measure for Medicare and Medicaid compliance.

• Bachelor Degree in Nursing with a compact Registered Nurse (RN) license, or multistate LMSW, required
• One (1) year hospital clinical experience, required
• One (1) year hospital discharge planning experience, required

• Holistic patient assessment for discharge planning needs
• Participate in hospital multidisciplinary daily rounds
• Identify patient and family education needs to ensure adequate participation in discharge planning
• Identify patient concerns regarding discharge, social risk factors and anticipate potential gaps in care
• Manage patient coordination of care across the care continuum
• Utilize research findings in practice, and participate in program development and implementation
• Coordinate with Hospitalists and advance practitioners to bridge care gaps
• Engagement of appropriate agencies or community resources when high-risk patients are identified
• Evaluate and update market Discharge Planning Resource to meet the market's healthcare disparity needs
• Establish and maintain professional relationships with physicians, nursing, county agencies, community resources, patients and their support system
• Facilitate decisions and communicate effectively regarding transitional care plans
• Maintain regulatory compliance with CMS Conditions of Participation and DNV NIAHO Accreditation Requirements
• Maintain a working knowledge of community resources related to professional scope of practice
• Knowledge of behavioral health systems, neglect and violence authority agencies, and community or financial resources for underserved or vulnerable populations
• Maintain patient health information privacy at all times and abide by company policies
• Functions as a liaison between the interdisciplinary treatment team and community partners
• Perform patient telehealth assessments
• Utilize financial and insurance resources to maximize the healthcare benefit to the patient
• Arrange post-discharge medical and community referrals for patients with health problems requiring further evaluation and/or additional services
• Apply advanced critical thinking and conflict resolution skills

• Excellent customer service and presentation skills
• Willingness to be a valued member on a team with an inspiring mission
• Ability to establish and maintain collaborative, effective working relationships
• Ability to communicate professionally and effectively in all platforms and forums
• Attend staff meetings or other company sponsored or mandated meetings as required
• Ability to manage multiple tasks simultaneously
• Demonstrate professional organization skills
• Perform additional duties as assigned
• Ability to work off-hours and on call when required
• Proficiency with Microsoft Office (Excel, Word, PowerPoint, TEAMS, OneDrive, and Outlook), required
• Proficiency in basic computer troubleshooting