RN Transitional Care Manager – Discharge & Care Coordination

CareRing Health, LLC; Richmond (VA); On-site; USD 70,000 - 95,000; Full time

Benefits offered by this job

Competitive pay

Weekly pay

Medical/dental/vision/life insurance

Paid holidays/PTO/401(k) match

Employee Assistance Program (EAP) with

Career growth opportunities

Collaborative work environment

Job summary

CareRing Health, LLC in Richmond, VA seeks a compassionate Transitional Care Manager to coordinate safe transitions from hospitals and post-acute facilities to home health services, bridging clinical, referral, and payer relationships to reduce readmissions.

Responsibilities include discharge planning, identifying suitable candidates for home health, conducting transitional assessments, educating patients and caregivers, and collaborating with hospital systems, physicians, and ACOs across

Qualifications

• RN license, active and in good standing in Virginia
• 2–3 years of clinical experience in home health, hospice, case management, or acute care discharge planning
• Working knowledge of Medicare home health Conditions of Participation and transitional care models (e.g., BOOST, RED, Coleman Model)
• Proficiency with EMR/home health documentation systems (e.g., WellSky)

Responsibilities

• Manage patient transitions from hospital/SNF discharge to home health start of care
• Coordinate discharge planning with hospital case managers and physicians
• Perform transitional care assessments (in-person or telephonic) to identify medication discrepancies and follow-up needs
• Monitor high-risk patients during the 30-day post-discharge window
• Collaborate with referral sources, payers, and home health team to resolve barriers
• Track readmission rates and quality metrics
• Support CMS Conditions of Participation in care coordination

Skills

Communication

Relationship-building

Discharge planning

EMR documentation

Education

BSN preferred

CCM certification preferred

Tools

WellSky EMR

Job description

CareRing Health, LLC in Richmond, VA seeks a compassionate Transitional Care Manager to coordinate safe transitions from hospitals and post-acute facilities to home health services, bridging clinical, referral, and payer relationships to reduce readmissions.

Responsibilities include discharge planning, identifying suitable candidates for home health, conducting transitional assessments, educating patients and caregivers, and collaborating with hospital systems, physicians, and ACOs across