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Transitional Care Management Jobs in Virginia (NOW HIRING)

Langer Recruiting, LLC

Transitional Care APP

Richmond, VA · On-site

$125K/yr

About the job Transitional Care APP Launched in 2022, At Home Harmony is revolutionizing healthcare ... Manage medical problems to assist patients in transitioning from the hospital or SNF to home with a ...

Lange Recruiting

Transitional Care APP

Richmond, VA

$125K/yr

As a Post-Acute/Transitional Care Nurse Practitioner or Physician Assistant with our practice, you ... Manage medical problems to assist patients in transitioning from the hospital or SNF to home with a ...

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Transitional Care Management information

See Virginia salary details

$31.2K

$52.4K

$92.2K

How much do transitional care management jobs pay per year?

As of Aug 18, 2026, the average yearly pay for transitional care management in Virginia is $52,421.00, according to ZipRecruiter salary data. Most workers in this role earn between $39,700.00 and $63,900.00 per year, depending on experience, location, and employer.

What is a transitional care management?

A Transitional Care Management (TCM) job involves coordinating care for patients as they transition from a hospital or skilled nursing facility back to their home or community setting. TCM professionals, such as nurses or care coordinators, ensure that patients receive follow-up care, medication management, and necessary support to prevent complications or hospital readmission. They communicate with healthcare providers, educate patients on their conditions, and address any barriers to recovery. The goal of TCM is to improve patient outcomes and enhance the continuity of care during this critical period.

What does a transitional care management professional do?

A Transitional Care Management professional is responsible for coordinating and overseeing a patient's care as they move between different healthcare settings, such as from hospital to home. Daily duties often include assessing patient needs, developing individualized care plans, facilitating communication between healthcare providers and family members, and ensuring all necessary follow-up appointments and medications are in place. They also work to identify and address potential barriers to recovery, such as social or environmental factors, to prevent hospital readmissions. The role involves close collaboration with physicians, nurses, social workers, and community resources to provide comprehensive support throughout the transition process.

What are the key skills and qualifications needed to thrive in transitional care management?

To thrive in Transitional Care Management, you need clinical expertise in patient care coordination, discharge planning, and chronic disease management, usually supported by a healthcare degree such as nursing, social work, or a related field. Familiarity with electronic health records (EHRs), care planning software, and current transitional care guidelines is highly valued, along with certifications like CCM (Certified Case Manager) or TCM (Transitional Care Management) when available. Outstanding organization, problem-solving, and interpersonal communication are essential soft skills for building relationships with patients, families, and multidisciplinary teams. These abilities are crucial for ensuring seamless transitions, reducing readmissions, and improving patient health outcomes during vulnerable periods of care transfer.

What are popular job titles related to Transitional Care Management jobs in Virginia?

For Transitional Care Management jobs in Virginia, the most frequently searched job titles are:

What job categories do people searching Transitional Care Management jobs in Virginia look for?

The top searched job categories for Transitional Care Management jobs in Virginia are:

What cities in Virginia are hiring for Transitional Care Management jobs?

Cities in Virginia with the most Transitional Care Management job openings:

Transitional Care Management jobs near you
Infographic showing various Transitional Care Management job openings in Virginia as of August 2026, with employment types broken down into 74% Full Time, and 26% Part Time. Highlights an 96% In-person, and 4% Remote job distribution, with an average salary of $52,421 per year, or $25.2 per hour.

Transitional Care APP

Langer Recruiting, LLC

Richmond, VA • On-site

$125K/yr

Other

Retirement

Posted 9 days ago

Job description

About the job Transitional Care APP
Launched in 2022, At Home Harmony is revolutionizing healthcare delivery. As a dynamic home-based medical and pharmacy practice, were passionate about transforming healthcare for seniors to provide exceptional care to our patients and families. Our team of dedicated medical providers is growing, and were seeking two experienced NPs/PAs to join our Post-Acute/Transitional Care Team.
As a Post-Acute/Transitional Care Nurse Practitioner or Physician Assistant with our practice, you will play a pivotal role in our mission to provide exceptional healthcare services directly to complex needs, homebound patients in the comfort of their homes or apartments or via telehealth. You will collaborate with our interdisciplinary team of pharmacists, nurses, MAs, phlebotomists, clinical liaisons, utilizing the latest tools and technology to enhance patient outcomes and streamline provider workflows.
If you are ready to make a difference and be part of this progressive team, come join us.
Why Join Us:

  • Cutting-Edge Technology: Be part of a team that embraces the latest advancements in healthcare technology including AI for ease of charting and remote patient monitoring devices in the home.
  • Flexible Schedule: Build your schedule with a combo billable in-person, telehealth, and chronic condition management.
  • No Holidays or Hospital Rounds: Focus solely on patient care.
  • 401(k) Retirement Plan: Invest in your future with our competitive retirement plan.
  • Leading the way: Join a practice utilizing Medicares latest programming to provide concierge care feel to practicing primary care in the home.
Your Role
  • Deliver transitional care/post-acute care in the patient's home or via telehealth. This involves driving or riding in your vehicle to the place of service.
  • Manage medical problems to assist patients in transitioning from the hospital or SNF to home with a possibility of managing a small panel of regular patients (as needed).
  • Perform comprehensive health assessments and diagnose and treat complex illnesses.
  • Analyze test data to diagnose, treat and arrange appropriate follow up for the patient to ensure continuity of care.
  • Follow At Home Harmony's Coordinated Model of Care of Medical and Pharmacy.
  • Use critical thinking skills and follow evidence-based standards of practice.
  • Accurately and thoroughly document your patient encounter in the EMR and ensure accuracy.
  • Educate patients and families on how to manage their health and well-being.
  • Effectively navigate difficult conversations related to end-of-life issues and goals of care.
  • Communicate effectively with patients, family, the medical power of attorney, other medical providers and all individuals involved in the patients care.
  • Adhere to clinical and safety standards, protocols, and performance metrics.
  • Provide care with compassion, empathy, and cultural competency.
  • Maintain positive relationships with Care Concierge and At Home Harmony staff.
  • Attend training sessions and clinical team meetings, as requested
  • Serve as ambassadors for At Home Harmony and maintain professional demeanor.
  • Display a flexible, adaptable attitude and proactive demeanor as our company continues to grow and thrive.
Experience and Qualifications:
  • Minimum of three years of experience as an APP in Post-Acute, SNF, Hospitalist, Geriatrics, Family Practice, Internal Medicine
  • Experience in home-based care a plus but desire to learn is welcomed
  • Graduate with an advanced degree from an accredited institution
  • Current unrestricted VA state license as a Nurse Practitioner or Physician Assistant
  • Nationally board certified, current
  • Current BLS required
  • Prescriptive authority and active DEA
  • Valid drivers license with clean driving record
  • Ability to lift and carry equipment up to 50 pounds
  • Ability to walk up and down several flights of stairs easily

Job status: Full time (0.8 FTE will be considered also)
Compensation Rate: Competitive starting at $125,000 (based on experience); Incentive/bonus program
Schedule: Flexible; Monday - Friday (within hours of 8-5)
At Home Harmony
Launched in 2022, At Home Harmony is an innovative home-based Medical and Pharmacy practice in Richmond, VA providing exceptional healthcare for aging adults with complex chronic conditions. We are experts in utilizing Medicares comprehensive programming to provide coordinated top-quality care. If you are seeking a meaningful, flexible opportunity in a team-oriented environment, consider a role with us. Bring your ideas, knowledge, passion, and dedication to our growing team and together we can make a difference in the lives of our beloved senior population.

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