Transitional Care Manager: Discharge & Care Coordination

AbsoluteCARE Medical Center & Pharmacy; Baltimore (MD); On-site; USD 81,000 - 99,000; Full time

Job summary

AbsoluteCare Medical Center & Pharmacy is seeking a Transitional Care Manager to lead discharge planning and post-discharge care coordination in the Baltimore area. You will engage with inpatients, coordinate with primary and specialty care, and work with community resources to meet each member’s post-discharge needs.

You will support medication reconciliation, care plan development, and timely follow-ups while meeting performance metrics and maintaining documentation accuracy in EMR systems.

Qualifications

• RN licensed in the practicing state.
• 3+ years serving complex populations in community or office settings.
• Second language ability is desirable for local populations.

Responsibilities

• Meet with inpatient members to develop PCCP for discharge and care transition.
• Call post-discharge members to review instructions and reconcile meds.
• Coordinate post-discharge plans with PCPs, specialists, and home health.
• Communicate with AbsoluteCare and community providers to resolve discharge barriers.
• Maintain PCCP and member contact per agency requirements and standards.
• Provide education using teach-back on health conditions and treatments.

Skills

Discharge planning

Care coordination

Communication skills

EMR documentation

Microsoft Office

Problem solving

Second language (desirable)

Education

RN license (state)

CCM or CCTM credential a plus

Tools

MCG criteria

ASAM criteria

Job description

AbsoluteCare Medical Center & Pharmacy is seeking a Transitional Care Manager to lead discharge planning and post-discharge care coordination in the Baltimore area. You will engage with inpatients, coordinate with primary and specialty care, and work with community resources to meet each member’s post-discharge needs.

You will support medication reconciliation, care plan development, and timely follow-ups while meeting performance metrics and maintaining documentation accuracy in EMR systems.