TRANSITIONAL CARE MANAGEMENT (TCM), RN

Oneida Health; City of Utica (NY); On-site; USD 75,000 - 95,000; Full time

Job summary

Oneida-Healthcare is seeking a Transitional Care Management (TCM) RN to support patients moving from inpatient stays to home care, coordinating with PCPs and outpatient teams. The RN will review discharge plans, document in Medent, and ensure timely follow-up after discharge.

The role emphasizes discharge planning, patient communication, and care coordination within New York state guidelines, with routine follow-up for 30 days as directed by the PCP.

Qualifications

• Current NY RN license is required.
• 2 years of nursing experience.
• Experience in medical office environment is a plus.

Responsibilities

• Identify eligible patients for TCM services and contact them within 2 business days.
• Schedule TCM visit with PCP within 7–14 days of discharge.
• Document all patient interactions in the Medent record.

Skills

Care coordination

Patient communication

Discharge planning

Medent documentation

Education

Associate degree in nursing

Bachelor of Science in Nursing

Tools

Medent EHR

RHIO access

Job description

Job Summary:The Transitional Care Management (TCM) RN plays a key role in supporting patients as they move from an inpatient (or observation) stay to home and resume care with their Primary Care Provider (PCP) and/or other outpatient providers. Utilizing internal systems and the Regional Health Information Organization (RHIO), HealtheConnections, the TCM Coordinator identifies eligible patients and ensures that each has a safe, timely, and appropriate follow-up care plan tailored to their individual needs.Key Responsibilities:Access internal reporting and the RHIO on a daily basis (Monday through Friday) to identify established patients who have been recently discharged from an inpatient (or observation) stay.Ensure a discharge summary is received in the patient’s Medent record for all discharges.Alert practice staff about transitions of care for patients not eligible for TCM services, via a triage document in the patient’s Medent record.Identify and contact patients eligible for TCM services by phone within two business days from the date of discharge.Document all patient contact in the Medent record using the TCM document, including any failed attempts to reach the patient.Review all aspects of the TCM form with the patient and document accordingly including documentation of pertinent patient information, medication reconciliation, assessment of barriers to care, establishing patient care goals and appropriate follow-up planning.Schedule a TCM visit with the PCP within 7 to 14 days of discharge, based on patient need.Provide ongoing and follow up assistance to patients for 30 days following discharge, as directed by the PCP.Track TCM appointments until completed. Follow up to ensure appropriate codes were applied and communicate with PCPs when coding needs to be modified to reflect the TCM visit.Maintain TCM visit tracking document.Complete other duties as assigned.Education:Associate of Nursing (Required)Bachelor’s of Nursing (Preferred)Certifications:BLS (Preferred)New York RN (Required)Experience:Nursing: 2 years (Required)Medical office environment: 1 year (Preferred)