Transitional Care Coordinator RN

Job Overview

The Transitional Care Coordinator (TCC), Nursing, is a Registered Nurse (RN) who manages the transition of patients identified as high-risk discharges, based on eligibility criteria, to ensure seamless continuity of care. The TCC supports patients as they move from the inpatient setting to their health home, outpatient specialty clinics, and community care teams within a designated timeframe—typically not exceeding 30-90 days post-discharge. This role ensures that barriers to care are identified and addressed, and that discharge planning continues until patients have stabilized and are successfully transitioned to their ongoing care teams. The position is responsible for managing patients with healthcare needs that place them at risk for poor outcomes due to gaps in care, fragmented or complex care plans, medical errors, delayed or duplicate treatments, and preventable or unnecessary emergency department visits or inpatient admissions.

Department Name: Care Coordination

Job Status: full time, 40 hours per week, eligible for benefits

Shift: variable hours between 0700-1800, Monday-Friday. No weekends or holidays.

This position is made possible by and is funded through third party grants and/or restricted funding. The length of the assignment and the FTE are dependent on the grant program and on funding availability. Based on current funding, there is no planned end date, but that is subject to change at any time. This position will be reviewed and may be extended in accordance with the grant. Should this position be discontinued and/or eliminated for any reason, it is not eligible for severance.

This position is eligible for relocation assistance, if relocating from 100 miles or greater.

Duties & Responsibilities

• Assesses, develops, implements, and evaluates a patient’s individualized post-acute care plan and identifies any barriers to the post hospital plan of care, making modifications as appropriate.
• Promotes quality, equitable and individualized care by integrating considerations of social determinants of health with comprehensive mental and physical health care plan, ensuring that all patients have access to quality care, optimal health outcomes, and exceptional healthcare experience.
• Uses data to support the evaluation and improvement of population outcomes in collaboration with leadership; Prevention of readmission and barrier mitigation are key outcomes.
• Provides patient assessment and support for comprehensive treatment regimen adherence and medication management, education to patient, guardian, family members and/or caregivers to support self-management and independent living and communicates with other members of the patient’s care team to ensure care coordination and safe transition back to the community.
• Collaborates with multidisciplinary team to identify resources to support the patient’s transition from hospital to identified setting, e.g. support with referrals, home health care, DME, medications, education, and partner in solving identified challenges.
• Partners with inpatient care team to proactively identify discharge barriers and effectively manage care transitions post-acute hospitalizations. Meets with patients and families before discharge to build rapport and continues intensive care coordination support post discharge via multiple modalities.
• Communicates (direct contact, telephone, video, electronic) with the patient and/or caregiver within designated standard timeframe of inpatient discharge.
• Engages with community resources including schools, pharmacies, specialty and primary care teams, and additional community-based partners.
• Proactively supports treatment adherence by using tools within electronic health record.
  
  

Minimum Qualifications

Education: Bachelor of Science in Nursing (BSN)

Experience: Three years nursing experience. Experience in inpatient, Intensive Care Unit (ICU) or care management settings preferred. Strong knowledge of community resources, Durable Medical Equipment (DME) processes, home health services, and insurance authorization workflows preferred.

Certification(s): BLS/CPR from the American Heart Association with at least 6 months left before expiration is required upon hire. Certified Case Manager (CCM) or Accredited Case Manager (ACM) certifications preferred.

Licensure(s): Registered Nurse (RN) licensure in the state of Colorado is required.

Salary Information

Pay is dependent on applicant's relevant experience.

Hourly Range: $41.87 to $62.81

Benefits Information

Here, you matter. As a Children’s Hospital Colorado team member, you will receive a competitive pay and benefits package designed to take care of your needs that includes base pay, incentives, paid time off, medical/dental/vision insurance, company provided life and disability insurance, paid parental leave, 403b employer match (retirement savings), a robust wellness program, and access to professional development tools, including an education benefit to help you advance your career.

As part of our Total Rewards package, Children's Colorado offers an annual employee bonus program that rewards eligible team members based on organizational performance. If organizational goals are met for the year, the bonus is paid out the following April.

Children’s Colorado delivers annual base pay increases to eligible team members based on their performance over the previous year.

EEO Statement

It is our intention that all qualified applicants be given equal opportunity and that selection decisions be based on job-related factors. We do not discriminate on the basis of race, color, religion, national origin, sex, age, disability, or any other status protected by law or regulation. Be aware that none of the questions are intended to imply illegal preferences or discrimination based on non-job-related information. The position is expected to stay open until the posted close date. Please submit your application as soon as possible as the posting is subject to close at any time once a sufficient pool of qualified applicants is obtained.

Colorado Residents: In any materials you submit, you may redact or remove age-identifying information such as age, date of birth, or dates of attendance at or graduation from an educational institution. You will not be penalized for redacting or removing this information.