CHRONIC CARE & TRANSITIONAL CARE NURSE

Position Title: CHRONIC CARE & TRANSITIONAL CARE NURSE

Requisition Number: CHRON003176

Location: Bowling Green, KY 42103, USA

Job Category: Nursing

Position Type: Full-Time

description:

Job Details

Description

Job Summary:

The Chronic Care & Transitional Care Management Nurse plays a critical role in identifying, supporting, and coordinating care for high-risk, chronically ill patients, including those receiving palliative care services. This role serves as a trusted, patient-friendly voice of reassurance—helping patients, caregivers, and providers navigate the complexities and early uncertainties following inpatient discharge.

The CCM/TCM Nurse supports value-based care initiatives by leading care coordination, transitional care outreach, medication reconciliation, quality metric monitoring, and care gap closure, while partnering closely with providers, clinical staff, hospitals, and payers.

Key Responsibilities:

Chronic Care Management (CCM)

• Identify and proactively support high-risk, chronically ill patients through ongoing care coordination and outreach
• Support patients receiving palliative care by facilitating care navigation, education, and communication across care teams
• Assist providers in developing, implementing, and updating individualized patient care plans
• Perform medication reconciliation and ensure medication accuracy across care settings
• Conduct mass patient communications (calls, messages, letters) related to care management, quality initiatives, and care reminders
• Monitor quality metrics and care gaps; assess patient quality measure status and initiate outreach to support closure
• Participate in quality improvement activities to improve outcomes and performance across value-based care programs
• Provide care navigation support, connecting patients to appropriate clinical, community, and post-acute resources

Transitional Care Management (TCM)

• Review daily inpatient discharge reports and payer ADT alerts to identify eligible patients
• Conduct patient outreach within 48 hours of inpatient discharge to assess needs, reinforce discharge instructions, and identify barriers to recovery
• Coordinate with providers, clinical staff, hospitals, and post-acute facilities to support safe transitions of care
• Maintain working knowledge of inpatient discharge processes, medication reconciliation, and post-discharge follow-up requirements
• Utilize hospital EMRs, payer data, ADT alerts, EMR tasks, and other discharge reporting tools to identify and outreach to patients

Collaboration & Operations

• Support providers and clinical teams with patient coordination, documentation, and follow-up needs
• Participate in staff meetings, case conferences, and interdisciplinary care discussions
• Document patient interactions, care plans, and outreach activities accurately and timely in the EMR

• Support all value-based care programs as needed, including quality, risk, and utilization management initiatives

Qualifications:

• Active RN or LPN licensure (RN preferred)
• Minimum of 3-5 years of clinical experience as an RN or LPN
• Strong communication skills with a compassionate, patient-centered approach

Preferred:

• Experience in primary care settings
• Knowledge of discharge planning and transitional care processes
• Experience with palliative care, chronic care management, or post-acute care
• Familiarity with hospital EMRs, payer ADT alerts, and value-based care workflows

Ideal Candidate Profile

The ideal candidate is calm, empathetic, organized, and proactive—someone who can serve as a reassuring presence for patients and families during vulnerable transition periods. This nurse is comfortable navigating complexity, collaborating across teams, and supporting both patients and providers in a value-based care environment.

Qualifications

SkillsRequiredDocumentationAdvanced Customer ServiceAdvanced ComputerAdvanced Attention to DetailAdvanced AnalyticalAdvanced AccuracyAdvanced Time-ManagementAdvanced Written CommunicationAdvanced Telephone EtiquetteAdvanced Teamwork AbilityAdvanced Reliable TransportationAdvanced Problem-SolvingAdvanced Patient CareAdvanced OrganizationalAdvanced Oral CommunicationAdvanced Multi-TaskingAdvanced Medical OfficeAdvanced InterpersonalAdvanced Electronic Medical RecordAdvanced BehaviorsRequiredTeam Player:Works well as a member of a groupLoyal:Shows firm and constant support to a causeDetail Oriented:Capable of carrying out a given task with all details necessary to get the task done wellDedicated:Devoted to a task or purpose with loyalty or integrity:MotivationsRequiredWork-Life Balance:Inspired to perform well by having ample time to pursue work and interests outside of workSelf-Starter:Inspired to perform without outside helpGrowth Opportunities:Inspired to perform well by the chance to take on more responsibilityAbility to Make an Impact:Inspired to perform well by the ability to contribute to the success of a project or the organization:EducationRequired

High School or Equivalent or better.

ExperienceRequiredActive RN or LPN licensure (RN preferred)Minimum of 3-5 years of clinical experience as an RN or LPNStrong communication skills with a compassionate, patient-centered approachPreferredKnowledge of discharge planning and transitional care processesExperience with palliative care, chronic care management, or post-acute careFamiliarity with hospital EMRs, payer ADT alerts, and value-based care workflowsLicenses & CertificationsRequired

Licensed Practical Nurse

Preferred

Registered Nurse

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.

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