Transitions of Care (TOC) Care Manager

Are you ready to join a passionate community of people who are changing how health care is delivered?  A place where you will find a career you love while truly making a difference building healthier communities.  If this sounds like you, we would love to have you apply as Transitions of Care (TOC) Care Manager, with Medical Home Network!

Since 2009, Medical Home Network (MHN) has partnered with Federally Qualified Health Centers (FQHCs) nationwide to transform care in the safety net, reduce health disparities, and build healthier communities. A mission-driven public benefit corporation, MHN helps FQHCs succeed in value-based care through technology, care model innovation, and strong partnerships. Our proven approach delivers leading health outcomes, lower costs, and elevated quality performance. We’re expanding our reach and impact to help more FQHCs enhance care for their patients. Modern Healthcare has named MHN one of the Best Places to Work in Healthcare for four years running (2021–2024). MHN was recently recognized as a Great Place to Work in 2025.

THE OPPORTUNITY:

The Transitions of Care (TOC) Care Manager provides care management on behalf of the ACO’s medical homes.  TOC Care Managers speak with patients at acute and specialty care hospitals to ensure safe transitions of care inpatient to ongoing care in the outpatient/ medical home setting.  The Care Manager will work collaboratively with the staff at hospital sites and at medical homes to facilitate better health outcomes and reduce readmission for patients.

• Fun, challenging, and collaborative work environment with passionate colleagues that care deeply about healthcare delivery.
• Recognized as One of the Best Places to Work in Healthcare by Modern Healthcare.
• Competitive benefits programs including Medical, Vision, Dental, HSA, FSA, and 401k.
• Fitness reimbursement, commuter benefits, and tuition assistance.
• Great work life benefits- Paid time off, sick time, and 12 paid holidays.
• Remote position
• This role will require working 1 weekend a month.

• Engage with patients during hospitalization focusing on; reasons for hospitalization, reinforcing care management plan of care, updating information for the Medical Home Care Management team, plan of care post-discharge, and goal setting. 
• Complete assessments as appropriate, such as risk screenings, initiate Care Plan, TOC Bundle, and others as needed.  
• Educate and support patients in health literacy, medication management, plan for follow-up and ongoing care, signs and symptoms of worsening conditions, functional or social needs, home and community-based services, advance directives, and other issues as identified. 
• Interface with hospital care team including nurses, social workers, case managers, hospitalists, and other staff responsible for utilization management and discharge planning. Engage with other stakeholders such as the patients’ family support network and external organizations the patient accesses for collaboration on patient success post-discharge. 
• Assess patient readiness for change and work with care team to ensure patients discharges to proper services. Identify and address barriers to assure an efficient and complete transitions of care. 
• Participate in care team meetings and Integrated Care Team collaboration as necessary. 
• Develop relationships with staff in inpatient hospitals (general acute and behavioral health) and Medical Home Care Management staff. Gather and share patients medical home information with the hospital care team; Gather and share information about the hospital stay to the medical home, including discharge planning documents. 
• Work with the patient and medical home to secure timely follow-up appointments. 
• Communicate and document activities and outcomes to the patient’s medical home care manager regularly. 
• Assist in leading transitions of care trainings for care management staff. 
• Participate in quality improvement initiative as identified. 
• Other duties as assigned. 

• Bachelor of Science in Nursing or Master’s Degree in Social Work LSW/LCSW 
• Current state licensure as RN, LSW, or LCSW required. 
• Minimum of 3-5 years of recent work in care management, safety net/public health hospitals, FQHCs, academic medical centers, ambulatory care, physicians’ group, professional practice, and/or experience working in Community Mental Health Centers, outpatient mental health services; or combination thereof. 
• Knowledge of and experience with systems used to improve population health and management of disease states such as diabetes, heart failure, COPD/asthma, mental health, and substance use. 
• Excellent oral, written, and interpersonal communication skills.   
• Ability to work independently and as part of a team with a wide range of individuals from a variety of care delivery sites and community agencies. 
• Excellent organizational skills and ability to be self-driven 
• Knowledge and experience with electronic information systems (EHRs, care management platforms). 
• Experience in program development and training/education. 
• Proficient computer skills 
• Nurse Case Management Credentialing (RN-BC) or Certified Case Manager (CCM) desirable. 
• Certified Alcohol and Other Drug Counselor (CADC) desired. 
• Knowledge and experience working with Medicaid and Medicare populations desirable. 
• Bilingual in Spanish preferred. 

Medical Home Network is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other protected characteristic. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.