RN Transitional Care Manager — Seamless Discharges

CareRing Health; Richmond (VA); On-site; USD 70,000 - 90,000; Full time

Benefits offered by this job

Competitive pay

Paid weekly

Medical/dental/vision/life insurance

Paid holidays/PTO/401(k) match

EAP with up to 6 free counseling per</

Career growth opportunities

Collaborative work environment

Job summary

CareRing Health in Richmond, VA is seeking a compassionate Transitional Care Manager to coordinate safe transitions from hospital and post-acute settings into home health services. You will collaborate with hospital case management, physicians, and the home health team to reduce readmissions and improve patient experience during a high-risk period.

The role requires an active RN license in Virginia, 2–3 years of relevant clinical experience, and proficiency with EMR systems such as WellSky.

Qualifications

• Active RN license in Virginia required.
• 2–3 years of clinical experience in home health, hospice, case management or discharge planning.
• Knowledge of Medicare home health Conditions of Participation and transitional care models.
• Strong communication and relationship-building skills across clinical, administrative, and referral stakeholders.
• Proficiency with EMR/home health documentation systems (e.g., WellSky).
• Valid driver's license and reliable transportation for local travel.

Responsibilities

• Coordinate patient transitions from hospital/SNF discharge through home health start of care.
• Discharge planning coordination with hospital case managers, discharge planners, and physicians.
• Perform transitional care assessments to identify medication discrepancies and follow-up needs.
• Monitor 30-day post-discharge period to prevent readmissions.
• Serve as liaison between referral sources, payers, and home health team to resolve barriers.
• Track readmission rates and start-of-care timeliness.
• Support CMS Conditions of Participation compliance related to care coordination.
• Collaborate with intake/referral team to reduce time from referral to start of care.
• Educate patients and caregivers on care plans and warning signs requiring escalation.
• Build relationships with hospital systems, SNFs, and physician groups in Central Virginia.

Skills

RN license

Home health experience

Discharge planning

Readmission reduction

Communication skills

EMR proficiency

Driver's license

Education

BSN

CCM certification

Tools

WellSky

Job description

CareRing Health in Richmond, VA is seeking a compassionate Transitional Care Manager to coordinate safe transitions from hospital and post-acute settings into home health services. You will collaborate with hospital case management, physicians, and the home health team to reduce readmissions and improve patient experience during a high-risk period.

The role requires an active RN license in Virginia, 2–3 years of relevant clinical experience, and proficiency with EMR systems such as WellSky.