Transitional Care Manager - USA Health Care

Transitional Care Manager

Key Responsibilities

A typical day includes:

• Patient Assessment:

  Screen all patients for discharge needs (regardless of race, age, sex, religion, diagnosis, or payment ability). Meet patients/families to develop individualized care plans with physicians and the healthcare team.

• Care Coordination:

  Facilitate communication across the multidisciplinary and post-acute teams; involve patients/families to reduce service fragmentation, manage resources, and remove barriers.

• Resource Management:

  Maintain up-to-date community resource knowledge; refer patients/families to appropriate services and consult external agencies.

• Discharge Planning:

  Collaborate on discharge plans that maximize patient benefit and meet continuing care needs.

• Documentation & Compliance:

  Document care coordination, education, referrals, and authorizations in the medical record. Provide CMS-required notices (e.g., Important Message 448 hours pre-discharge, HINN, appeal notices).

• Multidisciplinary Engagement:

  Participate in rounds, committees, and workgroups; escalate quality issues, length-of-stay barriers, and discharge impediments promptly.

• Ongoing Evaluation:

  Reassess progress weekly or upon medical changes; revise plans and update records accordingly.

• Patient Education:

  Supply discharge options, risks/benefits, and available benefits; utilize social determinants of health screening tools.

• Crisis & Specialized Support:

  Collaborate on crisis intervention, counseling, abuse/neglect reporting, adoption, guardianship, psychosocial assessments, capacity management, and hospital throughput.

• Referrals (as needed):

  Acute/Sub-Acute Rehab, Long-Term Care, Assisted Living, Adult Day Programs, PASRR/EARC screening, Home Care, Hospice, DME, Transport, Dialysis, Financial/Medication Assistance, Palliative Care, Boarding Homes, Mental Health, Homelessness, Substance Abuse, Child/Adult Protective Services.

• Platform Proficiency:

  Maintain annual competencies in Epic, Xsolis Cortex, BI, Google Suites.

• Other Duties:

  Adhere to organizational competencies; perform additional projects as assigned.

Qualifications

Required

• Education:

  Bachelor’s in Nursing or related field

  OR

  Master’s in Social Work.

• Skills:

  Strong decision-making, creative problem-solving, influential leadership, excellent verbal/written/presentation skills, moderate-to-expert computer proficiency, familiarity with hospital/community resources and utilization management.

• Technical:

  Proficient in Microsoft Office/Google Suite.

Preferred (India-Specific)

• Education:

• MBBS

  (Bachelor of Medicine, Bachelor of Surgery)

• Pharm.D

  (Doctor of Pharmacy)

• M.Sc. Nursing

• M.Pharm

  (Master of Pharmacy)

• MSW

  (Master of Social Work)

• B.Pharm

  (Bachelor of Pharmacy)

• GNM

  (General Nursing and Midwifery) diploma with relevant experience
• or equivalent healthcare qualification in India.

(Doctors [MBBS] and Pharm.D/M.Pharm candidates are highly encouraged, especially for roles involving medication reconciliation, pharmacotherapy, and complex clinical decision-making.)

• Experience:

  2–3 years in care coordination, case management, transitional care, or clinical pharmacy (US/international exposure preferred). Hands-on

  eClinicalWorks EHR

  experience highly valued.

• Communication:

  Fluent English with clear, professional articulation for US patients; strong grasp of American accents and cultural nuances.

• Certifications:

• MCI registration (for MBBS)
• INC registration (nurses)
• PCI registration (pharmacists)
• or equivalent for social workers
• CCM (or obtain within 6 months), BLS/CPR (nurses), BCPS (pharmacists) a plus.

• Knowledge:

  US healthcare systems, Medicare/Medicaid guidelines, TCM codes (CPT 99495/99496); proficiency in Epic, Cerner, eClinicalWorks, and telehealth platforms.

• Availability:

  Full in-office commitment during US hours (6:00 PM – 2:30 AM IST).

• Technical Setup:

  Company-provided systems; dedicated in-office workspace.

Contact for Details or to Apply: