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, with 10–12 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 10–12 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 5,000 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:
- Engaging and community focused culture
- Competitive Salaries
- Opportunity for professional career growth
- Robust benefits for full-time and regular part-time roles, including Generous PTO; Choices in insurance; HSA; Tuition reimbursement; immediate 401K match; discounted tickets to various entertainment, social, and sporting events
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.
Nearest Major Market: Waukesha
Nearest Secondary Market: Milwaukee