Transitional Care Manager, RN
Job Description
Location: San Antonio, TX (Hybrid)
We are seeking a Transitional Care Manager, RN to own post-discharge care coordination for high-risk members enrolled in a Medicare Advantage plan. This position is a full-time, direct hire opportunity based in the San Antonio, TX area on a hybrid schedule.
This role is best aligned for an experienced RN who wants to keep using clinical judgment daily without returning to the floor. You will carry your own panel of recently discharged members, reconcile their medications, untangle their benefits, and get them to follow-up before a preventable readmission happens. The ideal candidate is comfortable working independently by phone, can read a discharge summary and immediately spot what is going to go wrong, and knows how to move a home health agency or a physician’s office when a member needs something today.
Responsibilities:
- Contact members within 24 to 72 hours of discharge to complete the transitional care assessment
- Reconcile discharge medications against pre-admission regimens and resolve discrepancies with prescribing providers
- Confirm member understanding of diagnosis, warning signs, activity restrictions, and self-care instructions
- Secure post-discharge follow-up appointments with primary care physicians and specialists within required timeframes
- Identify barriers to a safe transition including transportation, food insecurity, housing instability, and caregiver gaps
- Connect members to community resources such as meal delivery, transportation assistance, and local support programs
- Verify home health orders, service initiation, and visit documentation with contracted agencies
- Coordinate with providers to reconcile care plans, transmit discharge summaries, and close open care gaps
- Build individualized transitional care plans documenting member status, goals, interventions, and follow-up actions
- Monitor readmission risk indicators and escalate clinically deteriorating members to the medical director
Qualifications:
- BSN required; MSN or active enrollment in a graduate nursing program preferred
- Active, unrestricted RN license required; compact or multi-state licensure preferred
- CCM credential preferred, or willingness to obtain within 12 months of hire
- Minimum of 3 years of clinical nursing experience required, with acute care or discharge planning background strongly preferred
- Minimum of 1 to 2 years of transitional care, case management, or care coordination experience preferred
- Working knowledge of Medicare Advantage post-acute benefits including SNF, home health, DME, and readmission reduction programs
- Experience with electronic care management platforms and EHR documentation preferred
- Strong telephonic member engagement, motivational interviewing, and independent caseload management skills
Schedule:
- Full-time position
- Hybrid schedule with a combination of on-site days in the San Antonio, TX area and remote days
- Standard business hours, Monday through Friday
Salary Range: The salary range for this position is approximately $80,000 – $100,000 annually ($38.46 – $48.08 per hour), based on experience and qualifications.
Interview Process:
Selected candidates will participate in a multi-step interview process, including an initial screening with TalentLNX followed by interviews with department leadership.
Equal Opportunity Employer: TalentLNX is committed to equal employment opportunity and a diverse, inclusive workforce. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.