RN Complex Care Coordinator Transitional Care Management (TCM)

We Are Hiring : RN Complex Care Coordinator Transitional Care Management (TCM)

Begin your story with ProHealth Care. We offer a warm collaborative culture and a team of professionals dedicated to exceptional patient care across the care continuum. This role is part of our Complex Care Management program and plays a vital part in supporting high-risk patients as they transition from the hospital to home.

Schedule Details :

Hybrid schedule with required onsite presence at Waukesha / Mukwonago locations. Remote work is available after successful completion of orientation and ongoing competency validation. This is not a self-scheduled role; hours follow department needs during standard daytime shifts.

What You Will Do

The Transitional Care Management RN is the first point of connection with recently discharged patients ensuring a safe well-coordinated transition home. This is a high-acuity fast-paced phone-based nursing role ideal for an RN who thrives in rapid prioritization independent critical thinking and complex problem solving.

You will :

Complete structured TCM outreach calls with1012 calls daily

Perform full medication reconciliation and triage clinical concerns

Coordinate urgently with pharmacies providers and specialists

Manage high-complexity patients (heart failure COPD anticoagulation chronic disease instability social barriers etc.)

Address time-sensitive issues e.g. medications follow up care coordination ect.

Submit safety reports and escalate concerns in real time

Document thoroughly in Epic and close care gaps

Collaborate with inpatient and ambulatory teams to ensure a smooth transition

This role requires the ability to stay organized while managing real-time clinical issues that often extend beyond the final scheduled call of the day.

What You Will Do :

Provide post-discharge Transitional Care Management (TCM) support through timely outreach calls to recently discharged patients. Complete full medication reconciliation reinforce the discharge plan assess symptoms identify safety issues and coordinate urgently with pharmacies providers and specialists. Manage 1012 complex calls daily with multiple tasks between calls. Address time-sensitive concerns (e.g. incorrect meds missing refills anticoagulation issues) and escalate when needed. Document all assessments and interventions in Epic. Collaborate across the care team to ensure safe transitions reduce readmissions and support patient self-management. Hybrid work available after completing onsite orientation ( this position will work onsite and remotely)

#LI-CJ #LI

• CA #CA

Remote after 3 months

Why Join ProHealth Care :

We have nearly 5000 dedicated clinical and non-clinical employees and physicians who work together every day to serve the health and well-being of our community. At ProHealth Care everyone contributes to the care our patients receive. And everyone is treated with kindness and respect in our welcoming environment.

This Position Will Offer You :

ProHealth Care is an equal opportunity employer and is committed to an inclusive work environment and values the perspectives of our people. We maintain a drug-free workplace and perform pre-employment substance abuse testing. All qualified applicants will receive consideration for employment without regard to race religion color national origin sex gender identity sexual orientation age status as a protected veteran among other things or status as a qualified individual with disability.

Required Experience :

IC

Key Skills

Senior Care,Hoyer Lift,Medical office experience,Dementia Care,Home Care,Nursing,Alzheimers Care,Administrative Experience,Meal Preparation,Medication Administration,Memory Care,Tube Feeding

Employment Type : Part-Time

Experience : years

Vacancy : 1