RN Transitions of Care Program Lead (Hybrid)

TalentLNX LLC; Charlotte (NC); Hybrid; USD 100,000 - 120,000; Full time

Benefits offered by this job

Hybrid work model

Job summary

TalentLNX LLC seeks a Transitions of Care Program Manager, RN, to lead a hospital-to-home care coordination program in Charlotte, NC. The role oversees post-discharge outreach, medication reconciliation, and follow-up scheduling across hospital, skilled nursing, and home-health partners, with on-site time at partner facilities.

The ideal candidate has a BSN, an active NC or compact RN license, a CCM credential is preferred, and at least four years in case management or discharge planning.

Qualifications

• BSN preferred; active, unrestricted NC/compact RN license required.
• CCM credential preferred.
• Minimum 4 years of case management, discharge planning, or transitions of care experience.
• Experience leading programs or teams.
• Experience coordinating care across acute and post-acute settings.
• Knowledge of readmission measurement, risk stratification, and CMS programs.
• Familiarity with medication reconciliation and post-discharge follow-up protocols.

Responsibilities

• Lead transitions of care across acute, skilled nursing, and home health settings.
• Define post-discharge outreach model: timing, staffing, escalation.
• Oversee post-discharge medication reconciliation and resolve discrepancies.
• Build follow-up scheduling pathways to confirm appointments before discharge.
• Risk stratify discharges to focus intensive support on high-risk patients.
• Coordinate handoffs between hospital, post-acute, and primary care teams.
• Monitor readmission rates by facility and service line.
• Lead outreach staff and set clear expectations.
• Partner with post-acute facilities on performance reporting.
• Connect patients with transportation, food, and caregiver resources.
• Report program performance and financial impact to leadership.

Skills

Care coordination

Discharge planning

Transitions of care

Program leadership

Readmission risk

Readmission programs

Medication reconciliation

Follow-up scheduling

Risk stratification

Cross-functional collaboration

Education

Bachelor of Science in Nursing

RN license (NC or compact)

CCM credential

Job description

TalentLNX LLC seeks a Transitions of Care Program Manager, RN, to lead a hospital-to-home care coordination program in Charlotte, NC. The role oversees post-discharge outreach, medication reconciliation, and follow-up scheduling across hospital, skilled nursing, and home-health partners, with on-site time at partner facilities.

The ideal candidate has a BSN, an active NC or compact RN license, a CCM credential is preferred, and at least four years in case management or discharge planning.