Transitional Care Case Manager Jobs in California

Salary Range: $95.09 - $128.37

Job Title: Manager, Transitional Care

Position Summary

The Manager of Transitional Care provides operational, clinical, and strategic leadership for the Transitional Care Program.

The Manager is accountable for organizational performance in transitional care across the continuum. This position directs transitional care operations including staffing, budgeting, quality outcomes, regulatory compliance, and strategic growth. The Manager leads, develops, and executes strategies supporting CMS TEAM, HRRP, Population Health, and Value-Based Care initiatives to improve outcomes and reduce readmissions. The position leads interdisciplinary care transitions and collaborates with physicians, ambulatory services, case management, post-acute providers, and executive leadership.

Statement of Accountability

Reports to:Chief Quality Officer

Supervises Transitional Care Nurses, Navigators, Care Coordinators and support staff.

Qualifications

Specify if qualifications are required or preferred

Education:

• BSN required
• Current California RN license and AHA BLS

Preferred:

• Master’s Degree in Nursing

Certifications:

• Certified Case Manager (CCM)

Work Experience:

• 5+ years in transitional care/case management/population health preferred
• 3+ years management experience preferred
• Experience with CMS TEAM, HRRP, TCM billing, value-based care, budgeting, quality reporting, and physician collaboration preferred.
• Epic reporting and clinical documentation, project management, and program development preferred
• Experience leading transitional care, care coordination, or population health programs preferred.

Essential Job Responsibilities

Achieving Results:

Key Components: assess, plan, evaluate, demonstrate initiative, quality of work, productivity

• Develops plans to improve care transitions and organizational performance.
• Directs daily operations and staff.
• Develops budgets and strategic plans for TCM.
• Monitors departmental and organization-wide KPIs including readmissions, ED revisits, patient satisfaction and quality metrics.
• Uses data to identify trends and implement evidence-based interventions.
• Presents performance metrics through dashboards and makes recommendations to executive leadership.
• Ensures timely post-discharge outreach and TCM workflows.

Demonstrates Skill:

Key Components: competency, job knowledge, organizational skills, analytical skill, management of information, employee & patient safety

• Uses Lean/PDSA and evidence-based improvement methodologies.
• Interprets clinical and operational transitional care data to guide decision-making.
• Leads evidence-based transitional care and change management across multidisciplinary teams.
• Develops standardized workflows that improve outcomes and create policies and procedures.
• Mentors leaders and staff.
• Promotes patient safety and interdisciplinary collaboration.

Planning & Coordinating:

Key Components: delegates, decision making, problem solving, management of resources

• Develops partnerships across the continuum of care.
• Leads multidisciplinary meetings related to readmission reduction initiatives.
• Coordinates organizational strategies related to CMS value-based programs.
• Collaborates with Quality, Case Management, Outpatient Services, Inpatient Care, Physicians, and Post-Acute Care facilities.
• Manages departmental resources and contracts.

Professionalism:

Key Components: dependability, interpersonal skills, teamwork, patient first ethic, customer service, communication skills, punctuality/attendance, receptiveness to criticism, judgment, confidentiality

• Models integrity and accountability.
• Builds collaborative relationships across departments and community partners.
• Represents the organization internally and externally.
• Promotes a culture of accountability, innovation, and continuous improvement.
• Supports employee engagement and demonstrates excellent customer service.

Improving the Organization:

Key Components: performance improvement, quality initiatives

• Leads organizational readmission reduction strategy.
• Maintains TCM quality dashboards and identifies opportunities for improvement.
• Leads implementation of consultant recommendations and best practices.
• Supports strategic initiatives related to care transitions and accreditation readiness.

Self-Development:

Key Components: maintain license/certification, education and training

• Maintains licensure.
• Participates in leadership development.
• Encourages staff certification and professional growth.Maintains knowledge of evolving CMS regulations and value-based payments related to care transitions and readmissions.

Regulatory Compliance:

Key Components: TJC, Title 22, OIG, HIPAA, State/Federal laws, hospital policies

• Ensures compliance with Joint Commission, CMS, HIPAA, Title 22 and hospital policies.
• Maintains survey readiness and staff competencies.
• Participates in regulatory reporting related to transitional care and related quality performance.