The Program Director, Transitional Care Management (TCM) is responsible for the operational, clinical, and programmatic leadership of the centralized Hospital-to-Home Transitional Care Management, Remote Patient Monitoring (RPM), and post-discharge appointment coordination programs. The Program Director oversees telehealth transitional care workflows, Monitoring Specialists, Patient Screening Navigators, and related program staff to support post-discharge outreach, follow-up care, remote monitoring, escalation workflows, and timely appointment scheduling.
The Program Director leads workflow standardization, staff training, KPI monitoring, reporting, and continuous improvement efforts to reduce preventable emergency visits and 30-day readmissions. This position reports to the VP, Associate Chief Logistics Officer and collaborates with clinical, operational, IT/Telehealth, informatics, rural hospital, case management, ambulatory practice, and community partners to sustain a scalable virtual transitional care program.
Provide operational and clinical leadership for the centralized TCM/RPM program, ensuring consistent program operations, timely follow-up, standardized care coordination, and safe transitions for enrolled patients within the leader’s applicable professional scope of practice. Establish and oversee patient identification, eligibility review, enrollment prioritization, and risk stratification processes to appropriately target high-risk post-discharge patients.
Oversee the Hospital-to-Home transitional care model, including post-discharge outreach, telehealth follow-up visits, transition-period monitoring, patient/caregiver education, and closed-loop communication with community providers. Provide direct or matrixed supervision of assigned clinical and non-clinical program staff, which may include APPs, nurses, physicians, monitoring specialists, patient screening navigators, and related team members, including recruitment, onboarding, competency validation, education, and performance support.
Develop, maintain, and operationalize TCM/RPM protocols, outreach scripts, medication reconciliation checklists, telehealth documentation standards, escalation pathways, workflow tools, and staff training materials. Build and maintain relationships with ambulatory practices, community providers, rural network hospitals, skilled nursing facilities, home health agencies, EMS partners, county public health departments, and community-based organizations to support timely follow-up and smooth care transitions.
Partner with IT/Telehealth, clinical informatics, and vendor teams to support telehealth platform configuration, scheduling workflows, documentation workflows, data capture, RPM workflows, and community provider coordination processes. Maintain operational readiness for RPM and virtual care services, including monitoring workflow design, clinical scenario review, escalation threshold refinement, readiness validation, and outpatient deployment support.
Lead outcome monitoring, performance improvement, and corrective action activities related to enrollment, outreach completion, telehealth visit completion, medication reconciliation, RPM adherence, escalation timeliness, care gap closure, patient engagement, avoidable utilization, and 30-day readmission reduction. Prepare routine performance updates for program governance, leadership review, funder reporting, and continuous improvement planning.
Collaborate with the Office of Research and Grants Administration on grant deliverables, narrative updates, voucher support, expenditure documentation, and compliance with program requirements. Ensure program workflows align with patient safety expectations, regulatory requirements, privacy/data governance standards, documentation requirements, reimbursement readiness, and organizational policies. Promote a culture of accountability, teamwork, patient-centered care, rural health access, health equity, and continuous improvement within the TCM/RPM program.
Develop scalable and sustainable operating models to support phased program expansion, staffing plans, governance engagement, resource stewardship, billing workflow readiness, and growth across future patient populations, service lines, and budget periods. Other duties as assigned. Qualifications/Requirements:
Minimum of 7 years of clinical experience as a licensed Advanced Practice Provider, Registered Nurse, or Physician in an acute care, ambulatory, transitional care, population health, telehealth, or care management setting, required. Minimum of 3 years of leadership, supervisory, program management, or clinical operations experience, required. Experience with transitional care management, post-discharge follow-up, readmission reduction, RPM, virtual care, population health, or cross-continuum care coordination, preferred.
Experience with quality improvement, KPI tracking, grant deliverables, program reporting, value-based care, population health, or rural health access initiatives, preferred. Experience with EHR systems, telehealth platforms, care management tools, or RPM dashboards, preferred.
Graduate of an accredited clinical professional program as applicable to discipline, required. Bachelor's degree, required for RN candidates. Master's degree or higher in Nursing, Physician Assistant Studies, Medicine, Health Administration, Public Health, Business Administration, or related field, preferred unless required by professional discipline.
Current Unrestricted MD License to practice medicine. Board Certified by the American Board of Medical Specialties (ABMS) or the American Board of Osteopathic Specialties (ABOS), preferred. Licenses /
Valid New York State license and current registration as a Physician Assistant, Nurse Practitioner, Registered Nurse, or Physician, as applicable to professional discipline, required. Current national certification or board certification as applicable to professional discipline, required when applicable. Prescriptive authority in New York State, required only for roles and duties requiring prescribing responsibilities, or must be obtained in accordance with organizational policy.
BLS certification, required. ACLS certification, preferred. Other: Strong clinical judgment with demonstrated ability to triage symptoms, identify risk, coordinate escalation, and support safe care transitions.
Ability to work collaboratively with physicians, APPs, nurses, case management, social work, IT, informatics, telehealth vendors, rural hospitals, and community partners while maintaining responsibilities within applicable scope of practice and organizational policy. Commitment to improving access, health equity, patient experience, and continuity of care for rural and underserved communities. Special
N/A Physical
Physical Activity (please check one box): ☐ Sedentary Work (involves sitting most of the time, occasionally walking and standing; requires lifting no more than 10 pounds at a time and/or occasionally lifting or carrying objects) ☒ Light Work (involves lifting no more than 20 pounds at a time with frequent lifting or carrying of objects weighing up to 10 pounds; requires moderate mobility to different work locations)