This is a fully remote position, open to applicants in New York.

📋 Description

• Evaluate and enhance the 30-day transitions-of-care / TCM pathway from discharge notification to in-home or virtual follow-up.

• Create effective protocols, escalation guidelines, documentation standards, and training for Nurse Practitioners, Registered Nurses, and Medical Assistants.

• Assist in operationalizing medication reconciliation, primary care provider follow-up, durable medical equipment, home health services, transportation, and caregiver support to lower readmission risks.

• Establish outcome reporting and aid in implementation alongside clinical, product, and engineering teams.

• Provide the team with a sustainable operational playbook and a clear transition for ongoing execution.

• Collaborate closely with the Chief Clinical Officer and the current clinical team.

⛳️ Requirements

• Significant responsibility in designing, implementing, or substantially enhancing a post-discharge, transitions-of-care, post-acute, or readmission-reduction solution.

• Experience in a care-delivery vendor, post-acute provider, or a risk-bearing care organization.

• Practical understanding of workflows for readmission prevention, clinical team training, health-plan quality measures, and utilization-focused care delivery.

• Proven success in translating a clinical model into operational practice and measurable outcomes.

• Background as a Senior Director, VP, or experienced clinical consultant is advantageous but not mandatory.

• Clinical licensure such as RN, NP, or a similar credential is beneficial but not required.

• Experience in client-facing implementation is advantageous but not mandatory.

• Familiarity with HEDIS, Stars, PCR, TRC, TCM documentation, ADT, or HIE workflows is beneficial but not required.