Transitions of Care, TCM Consultant

Urrly

. Assess and refine the 30-day transitions-of-care / TCM pathway from discharge notification through in-home or virtual follow-up .

Posted 10/6/2026contractRemote • New York • United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in designing and implementing transitions-of-care solutions, with a focus on reducing readmission risks through effective clinical workflows and team training. Proficient in developing protocols and documentation standards to support operational excellence in post-acute care settings.

Highest-signal resume keywords

Transitions-Of-Care DesignReadmission Prevention WorkflowsClinical Team TrainingHEDIS FamiliarityClient-Facing Implementation Experience

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Post-Acute Care SolutionsMedication ReconciliationOutcome ReportingCare Delivery ImprovementDocumentation Standards

Soft Skills

Operational LeadershipTeam CollaborationCommunication Skills

Tools & Technologies

HIE WorkflowsTCM DocumentationADT Systems

Certifications & Qualifications

RN LicensureNP Credential

Industry Keywords

Care-Delivery VendorRisk-Bearing Care OrganizationHealth-Plan Quality MeasuresUtilization-Focused Care DeliverySenior Director Experience

About the role

Key responsibilities & impact

Assess and refine the 30-day transitions-of-care / TCM pathway from discharge notification through in-home or virtual follow-up
Develop practical protocols, escalation rules, documentation standards, and training for NPs, RNs, and MAs
Help operationalize medication reconciliation, PCP follow-up, DME, home health, transportation, and caregiver support to reduce readmission risk
Define outcome reporting and support implementation with clinical, product, and engineering teams
Leave the team with a sustainable operating playbook and clear handoff for ongoing execution
Work directly with the Chief Clinical Officer and existing clinical team

Requirements

What you’ll need

Meaningful responsibility for designing, implementing, or materially improving a post-discharge, transitions-of-care, post-acute, or readmission-reduction solution
Experience in a care-delivery vendor, post-acute provider, or risk-bearing care organization
Practical knowledge of readmission prevention workflows, clinical team training, health-plan quality measures, and utilization-focused care delivery
Track record of translating a clinical model into live operations and measurable results
Senior Director, VP, or experienced clinical consultant background is helpful, not required
Clinical licensure such as RN, NP, or a comparable credential is helpful, not required
Client-facing implementation experience is helpful, not required
Familiarity with HEDIS, Stars, PCR, TRC, TCM documentation, ADT, or HIE workflows is helpful, not required

Benefits

Comp & perks

Consulting fees are negotiable based on experience, deliverables, and capacity
Hourly, project-based, and fractional arrangements will be considered
Flexible engagement scope, timing, capacity, and fees
Response to applications within 24 hours