ARNP Transitional Care Management
Updated 12/03/25
Seattle, Washington, United States
Nurse Practitioner
Other
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Job at a glance
Degree Required
Other
Position Type
Full-Time
Work Environment
Long-Term Care/Facility
Home Care/House Calls
Telemedicine
Visa Sponsorship
No
Experience Level
2 years
Job description
Job description
The Transitional Care Management (TCM) Nurse/Coordinator plays a key role in ensuring continuity of care for patients transitioning from an inpatient facility (hospital, SNF, rehab, etc.) to the home or outpatient setting. This position focuses on reducing readmissions, supporting safe transitions, improving patient outcomes, and enhancing the overall patient experience.
Job Responsibilities
• Provide telephonic or in-person follow-up care coordination within 14 days of discharge per CMS guidelines.
• Collaborate with physicians, nursing staff, social workers, and other healthcare providers to develop and implement post-discharge care plans.
• Ensure timely scheduling of follow-up appointments, medication reconciliation, and access to necessary home care or equipment.
• Educate patients and caregivers about diagnosis, medication regimen, follow-up appointments, and signs of complications.
• Monitor patients for signs of potential readmission and intervene early as needed.
• Document TCM activities according to regulatory standards and billing requirements.
• Track outcomes, including readmission rates and patient compliance.
• Identify gaps in care and work with multidisciplinary teams to improve transitional processes.
Qualifications
1. Must be a U.S. citizen or hold an appropriate Visa to apply.
2. Must be eligible for or hold an unrestricted license in the state you choose to practice in.
a) WA (Washington)
b) AK (Alaska)
c) OR (Oregon)
3. Possess or be eligible for a DEA license, NPI number, and have prescriptive authority.
4. Board eligible/certified by the time of employment.
5. Must be eligible to participate in Medicare/Medicaid programs.
6. Certification in Case Management or Care Coordination required.
Working Hours
Flexible Schedule
• Primarily remote setting with some patient home or clinic visits.
• Requires sitting, standing, and walking.
• May involve travel to various facilities or patient homes (if applicable).
Skills
• Knowledge of community resources, healthcare delivery systems, and transitional care best practices.
• Excellent communication, organizational, and interpersonal skills.
• EMR proficiency and accurate documentation skills.
• Ability to work independently and as part of a multidisciplinary team.
Required Education and Preferred Experience:
1. Must have graduated from an approved ARNP program.
2. Experience in primary care, hospital, or skilled nursing home or equivalent preferred, but new graduates from ARNP program are encouraged to apply.
By applying you agree to our Terms of Service