RN Care Manager, Care Transitions in Rockville, Maryland at Avail Health

Role OverviewAvail Health is launching a hospital-based Care Transitions Program supporting Medicare patients with complex medical, behavioral health, and social needs following discharge. The RN Care Manager leads the medical track of that program — serving as the primary clinical point of contact for assigned patients throughout the 30-day TCM episode.
Day-to-day you’ll conduct post-discharge outreach, perform clinical assessments, complete medication reconciliation, prepare pre-visit summaries for the NP’s TCM encounter, and coordinate the referrals and services that keep high-risk patients from bouncing back. You’ll work closely with the SW Care Manager, who leads the behavioral health track, collaborating cross-functionally when medical and BH complexity overlap. Most of your work is virtual, with in-person visits when patients require assessment that can’t be done via telehealth.
This is a founding team role. You’ll help operationalize workflows, shape clinical protocols, and build a model designed to scale.What You'll Own• Post-discharge outreach and ongoing clinical contact for assigned medical-track patients throughout the 30-day TCM episode
• Medication reconciliation and clinical assessment prior to the NP’s TCM encounter
• Pre-visit chart preparation and clinical synthesis for the NP visitWhat You'll Do• Conduct post-discharge outreach within CMS TCM timelines; perform tuck-in calls for high-risk patients to validate discharge plan adherence and identify early barriers to safe transition
• Assess patient condition, symptom burden, functional status, medication adherence, fall risk, and social barriers across the TCM episode
• Complete medication reconciliation and coordinate resolution of discrepancies with the NP
• Perform pre-visit chart prep: review discharge summaries, HIE data, and medical records to identify clinical risks and gaps prior to the NP’s TCM encounter
• Coordinate referrals, follow-up appointments, home services, and community resources to support safe transitions
• Conduct in-person visits when patients require licensed assessment that cannot be completed virtually
• Collaborate daily with the NP, SW Care Manager, and Care Coordinator in team huddles; present clinical priorities using SBAR and contribute to risk stratification
• Consult with the SW Care Manager on psychosocial and BH barriers for medical-track patients; provide clinical input to the SW for BH-panel patients with medical complexity
• Maintain timely, accurate documentation in compliance with TCM billing requirements and CMS guidelinesWhat Success Looks Like• Post-discharge outreach completed within CMS TCM timelines for 100% of assigned medical-track patients
• Medication reconciliation completed and discrepancies resolved prior to every NP TCM visit
• Pre-visit clinical summaries complete and available to the NP before every scheduled encounter
• 30-day readmission rate for the assigned medical-track panel at or below program benchmarks
• Referrals, follow-up services, and care plan coordination completed without gaps across the patient panelWhat You BringRequired:
• ADN or BSN from an accredited program; BSN strongly preferred
• Active, unrestricted Maryland RN license in good standing
• 3+ years of clinical RN experience with direct responsibility for transitions of care, TCM, hospital discharge planning, post-acute care coordination, or readmission reduction
• Experience in mobile care delivery (home health, hospice, or house call settings) with medically complex adult or geriatric populations
• Strong clinical assessment, medication reconciliation, escalation, and interdisciplinary care coordination skills
• Familiarity with CMS TCM requirements and documentation standards
• Valid driver’s license, reliable transportation, and active automobile insurance
• Reliable high-speed internet and a dedicated, HIPAA-compliant home workspace

Preferred:
• Experience in longitudinal care management, complex case management, behavioral health care coordination, or population health for high-risk Medicare populations
• Familiarity with telehealth platforms, HIE systems, or ambient AI documentation tools
• Experience in an early-stage or startup-style healthcare environment with evolving workflowsSchedule and Work StyleWork Type: Hybrid — primarily remote with in-person visits when clinically indicated
Schedule: Monday–Friday, 8:00 AM – 5:00 PM ET; occasional on-call as program scales
Travel: Field visits across Montgomery County, MD; must reside within commuting distance of Rockville
Autonomy: High clinical independence with daily interdisciplinary team touchpointsCompensation and PerksSalary Range: $94,000 – $115,000 annually, commensurate with experience
Key Benefits:
• Medical, dental, and vision insurance
• HSA | 401(k) with employer match
• 15 days PTO | 8 + 1 floating holidays
• Professional liability and malpractice insurance provided
• All devices for clinical and technology-related activities providedAbout Avail HealthAvail Health is a Nurse Practitioner–founded organization delivering mobile and virtual care to Medicare-age patients. We combine technology, operational rigor, and clinical excellence to improve outcomes for complex populations. For more visit www.availhealthcare.co