CHRONIC CARE & TRANSITIONAL CARE NURSE

The Chronic Care & Transitional Care Management Nurse plays a critical role in identifying, supporting, and coordinating care for high-risk, chronically ill patients, including those receiving palliative care services. This role serves as a trusted, patient-friendly voice of reassurance—helping patients, caregivers, and providers navigate the complexities and early uncertainties following inpatient discharge.

The CCM/TCM Nurse supports value-based care initiatives by leading care coordination, transitional care outreach, medication reconciliation, quality metric monitoring, and care gap closure, while partnering closely with providers, clinical staff, hospitals, and payers.

• Identify and proactively support high-risk, chronically ill patients through ongoing care coordination and outreach
• Support patients receiving palliative care by facilitating care navigation, education, and communication across care teams
• Assist providers in developing, implementing, and updating individualized patient care plans
• Perform medication reconciliation and ensure medication accuracy across care settings
• Conduct mass patient communications (calls, messages, letters) related to care management, quality initiatives, and care reminders
• Monitor quality metrics and care gaps; assess patient quality measure status and initiate outreach to support closure
• Participate in quality improvement activities to improve outcomes and performance across value-based care programs
• Provide care navigation support, connecting patients to appropriate clinical, community, and post-acute resources

• Review daily inpatient discharge reports and payer ADT alerts to identify eligible patients
• Conduct patient outreach within 48 hours of inpatient discharge to assess needs, reinforce discharge instructions, and identify barriers to recovery
• Coordinate with providers, clinical staff, hospitals, and post-acute facilities to support safe transitions of care
• Maintain working knowledge of inpatient discharge processes, medication reconciliation, and post-discharge follow-up requirements
• Utilize hospital EMRs, payer data, ADT alerts, EMR tasks, and other discharge reporting tools to identify and outreach to patients

• Support providers and clinical teams with patient coordination, documentation, and follow-up needs
• Participate in staff meetings, case conferences, and interdisciplinary care discussions
• Document patient interactions, care plans, and outreach activities accurately and timely in the EMR

·         Support all value-based care programs as needed, including quality, risk, and utilization management initiatives

• Active RN or LPN licensure (RN preferred)
• Minimum of 3-5 years of clinical experience as an RN or LPN
• Strong communication skills with a compassionate, patient-centered approach

• Experience in primary care settings
• Knowledge of discharge planning and transitional care processes
• Experience with palliative care, chronic care management, or post-acute care
• Familiarity with hospital EMRs, payer ADT alerts, and value-based care workflows

The ideal candidate is calm, empathetic, organized, and proactive—someone who can serve as a reassuring presence for patients and families during vulnerable transition periods. This nurse is comfortable navigating complexity, collaborating across teams, and supporting both patients and providers in a value-based care environment.