Transitions of Care / TCM Consultant

Consulting fees are negotiable based on experience, deliverables, and capacity. Hourly, project-based, and fractional arrangements will be considered. Additional preparation and delivery time, total weekly commitment, and engagement duration will be agreed based on scope.

• Assess and refine the 30-day transitions-of-care / TCM pathway from discharge notification through in-home or virtual follow-up.
• Develop practical protocols, escalation rules, documentation standards, and training for NPs, RNs, and MAs.
• Help operationalize medication reconciliation, PCP follow-up, DME, home health, transportation, and caregiver support to reduce readmission risk.
• Define outcome reporting and support implementation with clinical, product, and engineering teams.
• Leave the team with a sustainable operating playbook and clear handoff for ongoing execution.

• Meaningful responsibility for designing, implementing, or materially improving a post-discharge, transitions-of-care, post-acute, or readmission-reduction solution.
• Experience in a care-delivery vendor, post-acute provider, or risk-bearing care organization.
• Practical knowledge of readmission prevention workflows, clinical team training, health-plan quality measures, and utilization-focused care delivery.
• A track record of translating a clinical model into live operations and measurable results.

• Senior Director, VP, or experienced clinical consultant background.
• Clinical licensure such as RN, NP, or a comparable credential.
• Client-facing implementation experience.
• Familiarity with HEDIS, Stars, PCR, TRC, TCM documentation, ADT, or HIE workflows.

• This is a consulting engagement, not a full-time clinical leadership role.
• Direct patient care is not the primary scope.
• A prior from-scratch launch is welcome, but not required; what matters is clear contribution to a working post-discharge model, implementation, improvement, or scale.
• Scope, timing, capacity, and fees will be discussed during the process.

At Urrly, fairness matters. Applications are evaluated against the same job-related requirements, including skills, certifications, and experience.

Apply now and get a response within 24 hours.