Manager, Transition of Care Registered Nurse

Why Join Grace at Home?

Grace at Home is a provider-led, community-based health and care partner dedicated to improving the health and well-being of those who need care the most, with a deep commitment to high-needs, urban and rural communities. Our local physicians, nurses, and caregivers work together to serve people and the communities they live in, beyond just treating symptoms. We remove barriers by delivering personalized care as close to home as possible, often in-home, because we know a deep understanding of our patient’s race, culture, and environment is critical to delivering improved health outcomes. By empowering patients, providers, and caregivers with the support they need, we strive to make health and care a reality—not a burden—every single day. Join us in creating a better way to care.

Overview

The Manager of Transitions of Care (TOC) Registered Nurse will oversee the operational execution of telephonic transitions of care programs to support safe and effective post-discharge transitions for members. This role will manage a team of telephonic care coordinators (nurses) and collaborate with clinical, quality, pharmacy and analytics teams to ensure timely outreach, medication reconciliation, follow-up care, and patient education. The Manager will help optimize workflows, monitor key performance indicators (KPIs), and ensure adherence to clinical and regulatory standards to reduce readmissions, improve quality outcomes, and enhance overall care coordination.

Duties & Responsibilities

Program Oversight & Coordination

• Supervise the daily operations of the telephonic transitions of care program, ensuring that post-discharge outreach is timely and effective.
• Implement and maintain standardized workflows and procedures for transitions of care, ensuring high-quality service delivery.
• Ensure members receive appropriate care post-discharge, including medication reconciliation, follow-up care, and education on managing their health conditions.
• Collaborate with internal teams (Clinical, Quality, Analytics) to monitor and report on key performance metrics, such as readmission rates, emergency department utilization, and care gaps.
• Support the alignment of TOC efforts with payer and value-based care arrangements to meet specific contract requirements.

Clinical & Operational Excellence

• Monitor and enforce adherence to established workflows, clinical guidelines, and regulatory standards to ensure the effectiveness of care transitions.
• Assist in developing and tracking key performance indicators (KPIs) related to transitions of care (e.g., outreach timeliness, readmission reduction, patient satisfaction).
• Collaborate with the Quality Assurance team to review performance and identify areas for continuous improvement.
• Ensure accurate clinical documentation in accordance with regulatory and organizational standards.

Team Leadership & Development

• Lead and support a team of telephonic care coordinators, providing guidance, mentorship, and ongoing training to ensure high-quality care delivery.
• Foster a collaborative, accountable, and patient-centered team culture.
• Support team members’ professional development and provide coaching to optimize workload management and job satisfaction.
• Help manage staffing models to ensure appropriate national coverage for all transitions of care activities.

Collaboration & Reporting

• Work closely with the analytics team to gather and analyze data on TOC performance, identifying trends, risks, and opportunities for improvement.
• Partner with internal teams (Clinical, Quality, Pharmacy, and Network teams) to address care gaps and ensure smooth transitions for members.
• Provide regular reports to leadership on the performance of transitions of care programs, highlighting key trends, successes, and areas for improvement.
• Assist in integrating TOC performance data into enterprise-level dashboards and workflows to enhance care management.

Continuous Improvement & Innovation

• Identify opportunities to enhance program effectiveness through process optimization, technology integration, and adherence to industry best practices.
• Stay informed on the latest evidence-based practices for transitions of care and industry trends.
• Contribute to the pilot and scaling of new initiatives aimed at improving patient outcomes, reducing readmissions, and enhancing the patient experience.
• May assist with outreach activities as needed to support program objectives.

Qualifications

• Qualifications
  • Licensure / Clinical Credential:
    • Active Registered Nurse (RN) license in good standing required.
    • Must hold an active, unrestricted Registered Nurse (RN) license in a Nurse Licensure Compact (NLC) state and maintain multistate licensure privileges.
  • Education:
    • Bachelor of Science in Nursing (BSN) required.
  • Experience:
    • Minimum of 3-5 years of experience in transitions of care, care management, or population health programs, with a focus on telephonic care coordination.
    • Experience working in value-based care models (e.g., ACOs, risk-based arrangements) is preferred.
    • Demonstrated ability to reduce readmissions, improve care outcomes, and manage complex care transitions.
  • Skills:
    • Strong operational management skills with the ability to manage and optimize daily workflows.
    • Proven ability to lead and support clinical teams in a telephonic or remote setting.
    • Proficiency in using care management platforms, Electronic Health Records (EHRs), and reporting tools.
    • Excellent communication, collaboration, and problem-solving skills across clinical, operational, and business teams.
    • Strong analytical skills and ability to use data to drive decision-making and process improvements.

• Preferred Qualifications:

  • Knowledge of transitions of care best practices and regulatory requirements.
  • Experience with performance improvement initiatives and quality metric tracking.
• Familiarity with patient-centered care models and patient education strategies.

Physical Requirements:

• Ability to sit for extended periods while performing office-based duties.
• Ability to use office equipment (computer, telephone, etc.).
• Ability to occasionally travel locally for meetings and training (up to 10% of time).

The working environment and physical requirements of the job include:

Work is performed indoors in a setting with air conditioning and artificial light. Travel to and work in offices or other environments is required. 

In this position you will need to communicate with customers, vendors, management, and other co-workers in person and over devices, sometimes with people who are agitated. Regular use of the telephone and e-mail for communication is essential. Sitting for extended periods is common. Must be able to receive ordinary information and to prepare or inspect documents. Lifting of up to 10 lbs. occasionally may be required. Good manual dexterity for the use of common office equipment such as computer terminals, calculator, copiers, and FAX machines. Good reasoning ability is important. Able to understand and utilize management reports, memos, and other documents to conduct business.

Equal Opportunity & Reasonable Accommodation Statement

Grace at Home is an Equal Opportunity Employer committed to creating an inclusive environment for all employees. We provide equal employment opportunities to all individuals regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other protected characteristic under applicable law.

If you require reasonable accommodation during the application or employment process, please inform the recruiter during the hiring process.

Disclaimer

This job description is intended to describe the general nature and level of work being performed. It is not intended to be an exhaustive list of all responsibilities, duties, and skills required. Management reserves the right to modify, add, or remove duties as necessary.

Our Benefits

Financial Well-being

• Competitive Compensation: We offer competitive salaries to attract and retain the best talent.
• 401(k) with Employer Match: Plan for your future with our 401(k) plan and a generous 4% employer match.

Health and Wellness

• Comprehensive Medical Plan: We proudly offer a comprehensive medical option with an employer contribution.
• Dental & Vision Coverage: Maintain your oral and eye health with our employer-paid dental and vision plans via MetLife.
• Employer-Paid Insurance: Life, Short-Term Disability (STD), and Long-Term Disability (LTD) insurance are provided at no cost to you.
• Generous Paid Time Off: Enjoy ample time off for rest and rejuvenation with generous PTO, holidays, and wellness time.

Additional Perks

• Continuing Medical Education (CME) Allowance for APPs: Stay at the forefront of your field with our CME allowance.
• Commuter Benefits: Save on your commute with our commuter benefits program.
• Mileage Reimbursement: Get reimbursed for work-related travel expenses.