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Transitional Care Management Jobs in Washington (NOW HIRING)

Luminis Health

Transitional Care - Lead RN

Annapolis, MD · On-site

$41.91 - $62.86/hr

Assists the department manager with administrative duties to include scheduling, performance ... Consistent with duties for Transitional Care RN's: designs, implements, and fosters care transition ...

Aledade PBC

Care Manager

Bethesda, MD · On-site

$70K - $85K/yr

Execute structured Episodic and Transitional Care Management (TCM) outreach following inpatient discharges and ED encounters within required timeframes. Complete required post-discharge medication ...

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$35.7K

$59.9K

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How much do transitional care management jobs pay per year?

As of Sep 12, 2026, the average yearly pay for transitional care management in Washington is $59,885.00, according to ZipRecruiter salary data. Most workers in this role earn between $45,300.00 and $73,100.00 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 Washington?

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

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

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

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Transitional Care Management jobs near you
Infographic showing various Transitional Care Management job openings in Washington as of August 2026, with employment types broken down into 81% Full Time, and 19% Part Time. Highlights an 92% In-person, and 8% Remote job distribution, with an average salary of $59,885 per year, or $28.8 per hour.

LPN Transitional Care Coordinator (Prince Georges County, MD)

Hyattsville, MD

Ennoble Care
Health Care and Social Assistance • 201 - 500 employees
Learn more about Ennoble Careexternal

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Re-posted 12 days ago

Key responsibilities

  • Coordinate care for patients in skilled nursing and rehabilitation facilities using Ennoble Care's EMR

  • Facilitate transitional care management by initiating services with the Housecalls division upon patient discharge and monitoring patient conditions

  • Communicate changes in patient condition promptly to providers, initiate interventions, and escalate care as needed

Ennoble Care rating

4.2

Company rating: 4.2 out of 10

Based on 6 frontline employees who took The Breakroom Quiz

Job description

About Us

Ennoble Care is a mobile primary care, palliative care, and hospice service provider with patients in New York, New Jersey, Maryland, DC, Virginia, Oklahoma, Kansas, Pennsylvania, Texas, Florida, and Georgia. Ennoble Care's clinicians go to the home of the patient, providing continuum of care for those with chronic conditions and limited mobility. Ennoble Care offers a variety of programs including, remote patient monitoring, behavioral health management, and chronic care management, to ensure that our patients receive the highest quality of care by a team they know and trust. We seek individuals who are driven to make a difference and embody our motto, "To Care is an Honor." Join Ennoble Care today!

Ennoble Care is seeking a full-time LPN (Licensed Practical Nurse) to serve as a Transitional Care Coordinator within one or more of our partnered long-term care facilities in Prince George's County, Maryland. The right person for this role is reliable, self-motivated, vigilant, and compassionate. This is an integral, on-site role as part of our clinical care team, working closely alongside our providers in a family-practice-style model built around continuity, relationship-building, and patient-centered support.

You'll get to know the residents (and their families) over time, monitor for changes in condition, and play a meaningful, hands-on role in helping people stay healthy, avoid unnecessary hospitalizations, and remain in their home -- where many of them want to be.

We're proud of the culture we've built at Ennoble Care -- one that is positive, respectful, and rooted in genuine teamwork. People here are valued, supported in doing work that matters, and encouraged to maintain a healthy work-life balance. We invest in our team's growth through internal advancement opportunities based on performance, organizational needs, and role availability, because we believe that when our team thrives, so do our patients.

ABOUT THE ROLE

At Ennoble Care, our mission is simple: To care is an honor. For our patients, that means we come to you, we care for you, and we're here for you -- and that belief is at the heart of everything we do. As an LPN Transitional Care Coordinator, you'll bring that mission to life -- working on-site within one or more of our partnered skilled nursing and rehabilitation facilities in Prince George's County, Maryland. Your focus will be transitional care management, attentive patient monitoring, and day-to-day collaboration with our clinical team and facility staff -- serving as a reliable communication bridge among residents, families, facility staff, and our Housecalls division -- keeping everyone informed and care on track.

REQUIRED QUALIFICATIONS 

  • Legally authorized to work in the United States of America
  • Active, unrestricted LPN license in the state of Maryland 
  • Minimum 1 year of patient-facing experience in a long-term care, skilled nursing or transitional care setting
  • Comfortable communicating proactively throughout the day in person, by phone, via email, and through Microsoft Teams
  • Solid working knowledge of healthcare terminology and care coordination principles
  • Strong clinical assessment skills with the ability to identify and escalate changes in condition
  • Experience with EMR systems and clinical documentation; Point Click Care experience preferred
  • Proficient with Microsoft 365 including Excel, Outlook, Word, and Teams
  • Excellent communication and interpersonal skills, with a solid foundation in organization, time management, and clinical documentation
  • Capacity to work independently while collaborating closely with multidisciplinary teams
  • Ability to work full-time in an on-site role Thursday-Monday based in the Prince George's County, Maryland area.
      • Daytime hours, approximately 8:00 a.m. to 4:30 p.m. EST 
      • No evenings
      • No over-night shifts
      • No on-call requirements
      • Seven (7) company-paid holidays annually
  • Ability to pass background check and drug screen
  • Transportation criteria:
    • Valid, unencumbered driver's license
    • Consistent and reliable transportation to fulfill the duties of this position
    • Current auto insurance, with the ability to provide proof

Please note, travel between facilities may be required

KEY RESPONSIBILITIES

Care Coordination & Transitional Care Management

  • Coordinate care for patients residing in skilled nursing and rehabilitation facilities using Ennoble Care's EMR
  • Facilitate transitional care management, ensuring services with the Housecalls division are initiated immediately upon a patient's discharge from the hospital
  • Expedite time to first provider visit for newly transitioned patients in accordance with established guidelines
  • Monitor patients attentively, communicate changes in condition promptly to the provider, initiate appropriate interventions, and escalate care as clinically indicated, including CCM-billable activities
  • Consistently support care coordination efforts to reduce avoidable emergency department visits and hospital readmissions
  • Collaborate daily with providers and facility staff to ensure care plans are kept current and acted on 

On-Site Clinical Support

  • Maintain a consistent and reliable daily on-site presence in assigned facilities
  • Build ongoing relationships with residents and their families, maintaining a consistent presence that reinforces trust and continuity of care over time
  • Conduct routine and urgent vital sign collection as needed
  • Perform regular patient check-ins to support care plans, follow-ups, and clinical stability
  • Identify changes in patient condition and promptly communicate concerns to the clinical team

Communication & Collaboration

  • Serve as a key liaison between Ennoble Care providers, facility staff, residents, families, and the Housecalls team
  • Collaborate closely with Ennoble Care providers within the skilled nursing or long-term care setting
  • Provide timely, accurate clinical updates to providers to support informed decision-making
  • Ability to convert two (2) eligible patients per day to Ennoble Care's Housecalls program
  • Serve as a steady communication bridge between residents, families, the facility team, and our Housecalls division
  • Function as a reliable communication bridge to ensure accurate, timely exchange of clinical information 

Documentation & EMR Management

  • Accurately document patient interactions, assessments, and care coordination activities in Ennoble Care's EMR 
  • Perform chart reconciliation to ensure accuracy and continuity of clinical records between Ennoble and facility records  
  • Follow established workflows, documentation standards, and escalation protocols 

Team Support & Leadership

  • Support onboarding and training of new Transitional Care Coordinators
  • Serve as a clinical mentor and resource for newly hired coordinators
  • Promote best practices in transitional care, communication, and facility-based care coordination
  • Contribute positively to team collaboration and foster strong partnerships with facility staff 
Work Environment & Expectations
  • Embedded, on-site role within assigned skilled nursing and/or rehabilitation facilities 
  • Requires consistent daily presence and strong relationship-building with facility staff 
  • Fast-paced, patient-facing role requiring clinical judgment, adaptability, and proactive engagement 
CORE COMPENTACIES 
  • Patient-centered care 
  • Clinical judgment and escalation 
  • Care coordination and continuity 
  • Communication and collaboration 
  • Documentation accuracy and compliance 
  • Relationship-building and teamwork 

COMPENSATION & BENEFITS

  • Starting salary: $55,000 annually
  • Quarterly bonus opportunities based on performance
  • Mileage reimbursement eligibility when traveling between facilities
  • Full-time health benefits eligibility, including a range of supplemental insurance options and elective benefits.

Thank you for your interest in joining the Ennoble Care team!❤️

#brown

Full-time employees qualify for the following benefits:

  • Medical, Dental, Vision and supplementary benefits such as Life Insurance, Short Term and Long Term Disability, Flexible Spending Accounts for Medical and Dependent Care, Accident, Critical Illness, and Hospital Indemnity. 
  • Paid Time Off
  • Paid Office Holidays 

All employees qualify for these benefits:

  • Paid Sick Time
  • 401(k) with up to 3% company match
  • Referral Program
  • Payactiv: pay-on-demand. Cash out earned money when and where you need it!

Candidates must disclose any current or future need for employment-based immigration sponsorship (including, but not limited to, OPT, STEM OPT, or visa sponsorship) before an offer of employment is extended.

Ennoble Care is an Equal Opportunity Employer, committed to hiring the best team possible, and does not discriminate against protected characteristics including but not limited to - race, age, sexual orientation, gender identity and expression, national origin, religion, disability, and veteran status. 

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