Registered Nurse (RN)-Transitional Care Management (TCM) & Medication Reconciliation

Kids for the Future; Augusta (GA); On-site; USD 70,000 - 95,000; Full time

Benefits offered by this job

Great Place to Work Certification

PTO and Paid Parental Leave

Mental Health Support Services

Retirement plan with employer match

Job summary

Center for Primary Care in the CSRA is seeking an experienced Registered Nurse for Transitional Care Management (TCM) and medication reconciliation. You will coordinate post-discharge care, review discharge summaries, and educate patients to ensure safe transitions back to the community.

The RN will collaborate with providers, care teams, caregivers, pharmacies, and community resources to reduce readmissions, support quality measures, and maintain thorough documentation in the electronic health

Qualifications

• RN license in the state of practice.
• At least two years of clinical nursing experience.
• Experience in ambulatory care, care management, population health, case management or transitional care preferred.

Responsibilities

• Review hospital discharge summaries and medication lists.
• Complete comprehensive medication reconciliation within required timeframes following discharge.
• Identify and resolve medication discrepancies, duplications, omissions, contraindications, and adherence concerns.
• Educate patients and caregivers on medication changes, dosing, side effects, and adherence strategies.
• Post-discharge outreach calls within required TCM timelines and coordinate timely provider appointments.
• Support billing requirements related to TCM services.

Skills

Chronic disease management

Care transitions

EMR documentation

Patient education

CMS TCM requirements

Education

Graduate of an accredited school of nursing

Tools

AthenaOne

Job description

• Location 4487 Columbia Rd,Augusta, GA, 30907,United States
• Employee Type Full-Time Non-Exempt
• Required Degree 4 Year Degree

Contact information

• Email [e-mail]

Description

Registered Nurse (RN)-Transitional Care Management (TCM) & Medication Reconciliation

Center for Primary Care

Whowe are:

Forover30yearstheCenterforPrimaryCare(CPC)hascaredforfamiliesintheCSRAbyprovidingpatientswith the most convenient, accessible, and personal healthcare available. Our mission is to improve the health and be goingof the familiesweservebyprovidingcompassionateandhigh-qualitycareinajoyfulsetting.Thephysicians,healthcareprofessionals,andsupportteamatour 10 practices,pluslaboratory,imaging,andcorporate locationsworktotransformourmissionintoaction.

What our employees say:

AtCenterfor Primary Care,weunderstandthatthework environmentisasimportantasthe hardwork youdo. Center for Primary Care is Great Place to Work Certified which means our employees share feedback on their workcultureexperiencesandwelistenandstrivetocreatepositiveemployeeexperiencescenteredonjoy,trust, andbelonging.

Learn moreaboutCPC’scultureand Great Place to WorkCertificationby clickingon thelinkbelow:

Coveragethatcaresforbody,mind,and spirit.

Retirementplanwithgenerousemployermatchandprofitsharing.

Mental Health Support Services.

PTO and Paid Parental Leave.

Registered Nurse (RN)-Transitional Care Management (TCM) & Medication Reconciliation

The Transitional Care Management (TCM) Registered Nurse is responsible for coordinating post-discharge care to reduce hospital readmissions, improve patient outcomes, and support quality measures. The RN performs medication reconciliation, patient outreach, care coordination, and education for patients transitioning from inpatient, observation, skilled nursing, or rehabilitation settings back to the community. The RN collaborates with providers, care teams, caregivers, pharmacies, and community resources to ensure safe and effective transitions of care.

Key Responsibilities:

Essential Functions

• Review hospital discharge summaries and medication lists.
• Complete comprehensive medication reconciliation within required timeframes following discharge.
• Identify and resolve medication discrepancies, duplications, omissions, contraindications, and adherence concerns.
• Collaborate with providers and pharmacists regarding medication-related issues.
• Educate patients and caregivers on medication changes, dosing, side effects, and adherence strategies.

Transitional Care Management

• Conduct post-discharge outreach calls within required TCM timelines.
• Assess patient understanding of discharge instructions and treatment plans.
• Evaluate symptoms, barriers to care, and risk factors for readmission.
• Schedule and coordinate timely post-discharge provider appointments.
• Ensure completion of TCM documentation in the electronic health record.
• Support billing requirements related to TCM services.

Care Coordination

• Communicate with hospitals, skilled nursing facilities, home health agencies, specialists, and primary care providers.
• Coordinate referrals, diagnostic testing, home services, and community resources.
• Escalate clinical concerns to providers as appropriate.
• Track patient progress through the post-discharge period.
• Reinforce discharge instructions and disease-specific education.
• Promote self-management and adherence to care plans.
• Provide education regarding red-flag symptoms and when to seek medical attention.
• Support patients and caregivers in navigating the healthcare system.

Quality and Performance

• Monitor and support reduction of avoidable readmissions and emergency department utilization.
• Maintain compliance with CMS, payer, and organizational requirements.
• Participate in quality improvement initiatives and population health programs.
• Maintain accurate and timely documentation.

Knowledge, Skills, and Abilities Required:

• Strong understanding of chronic disease management and care transitions.
• Knowledge of CMS Transitional Care Management requirements.
• Excellent communication and patient education skills.
• Ability to prioritize multiple tasks and manage a high-volume patient panel.
• Strong critical thinking and problem-solving abilities.
• Proficiency in EMR documentation and care management software.
• Knowledgeable of electronic medical record system and Microsoft Office suite.
• Ability to work both independently and in a team environment.
• Effective verbal and written communication skills.
• Demonstrates, through behavior, Center for Primary Care’s Mission Statement.
• Takes responsibility for providing exceptional customer service.
• Maintains patient confidentiality at all times; adheres to all HIPAA guidelines.
• Follows CPC guidelines, infection prevention practices, demonstrates appropriate use of PPE, performs hand washing according to policy, and follows safety and workplace incident procedures.
• Performs miscellaneous job-related duties as assigned.

All essential functions must be performed. Reasonable accommodations may be made to enable individuals with qualified disabilities to perform the essential functions . The above information is intended to describe the general nature and level of work being performed by people assigned to this job. It is not intended to be an exhaustive list of responsibilities, duties and skills required of personnel so classified. Examples listed do not preclude the performance of other duties similar in nature or in level of complexity.

Requirements

Qualificationsfor Success:

Education, License/Certification, and Experience Requirements

Education: Graduate of an accredited school of nursing.

Licensure, Certification or Registration Required: Current Registered Nurse (RN) license in the state of practice.

Experience: At least two (2) years of clinical nursing experience required. Experience with AthenaOne strongly preferred. Experience in ambulatory care, care management, population health, case management, chronic disease management, or transitional care preferred. Experience with medication reconciliation and electronic health records preferred.

Additional Job Details:

Work Setting: On-site

JobType: Full-Time

Schedule: Monday-Friday

Compensation: Marketcompetitivebasepay,commensuratewitheducationand experience.

Summary

Center for Primary Care isan equal opportunity employer and complieswith federal,state,and local anti-discrimination laws, regulations, and ordinances.