Supervisor Transitional Care

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Department:
Transitional Care

Under the director of the Director of Continuum of Care, the Supervisor of the Transitional Care Department provides leadership and oversight for daily operations within the Transitional Care Department.

This role ensures the effective implementation of programs to support high-risk patients and reduce hospital readmissions in compliance with the Centers for Medicare & Medicaid Services (CMS) Hospital Readmissions Reduction Program (HRRP).

The Supervisor collaborates with the Director to meet organizational goals, enhance patient outcomes, and deliver exceptional post-hospital care while maintaining responsibility and oversight of a patient population.

1.

Operational Leadership
• Supervise and coordinate the day-to-day activities of the Transitional Care team, including nurses,
social workers, and support staff.
• Monitor workflow, assign tasks, and ensure timely and effective delivery of transitional care
services.
• Implement and monitor quality improvement initiatives approved by the Director to align with CMS
HRRP and organizational goals.
• Functions as a liaison to the Department Director and Medical Directors.

2.

Team Management
• Provide coaching and mentorship for team members.
• Support professional development by identifying training needs and coordinating educational
opportunities.
• Promote a culture of collaboration, accountability, and patient-centered care within the department.

3.

Patient Care Oversight
• Maintains responsibility for a specific patient population and performs all functions as a

Transitional Care Coordinator in addition to supervisor job duties.

• Ensure high-risk patients receive appropriate follow-up care, education, and resources post discharge.
• Collaborate with interdisciplinary teams to identify patients at risk of readmission and develop
tailored care plans.
• Serve as an escalation point for complex patient cases requiring additional support or intervention.

4.

Data Management & Reporting
• Track and analyze data related to HRRP measures and patient outcomes, identifying trends and
opportunities for improvement.
• Assist with preparing and present performance reports to the Director and other stakeholders.
• Assist in maintaining compliance with regulatory requirements and accreditation standards.

5.

Program Development
• Foster partnerships with community resources to enhance patient support networks.
• Identify and implement evidence-based practices to improve care transitions and patient
satisfaction.

Performs other duties as assigned.

Education: Bachelor's degree in Nursing required; Master's degree preferred.

Licensure: Current State of California Registered Nurse (RN) license required.

Experience/Knowledge: Three (3) years of experience in transitional care, case managemen...