Transitions of Care / TCM Consultant

About the role

This consulting engagement helps a growth‑stage healthcare services and technology company turn its post‑discharge service line into a repeatable operating model that reduces avoidable hospital readmissions. You will work directly with the Chief Clinical Officer and an existing clinical team to assess, improve, and document the transitions‑of‑care pathway.

Key responsibilities

• 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.
• 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.
• Deliver a sustainable operating playbook and clear handoff for ongoing execution.

Required profile

• Proven responsibility for designing, implementing, or materially improving a post‑discharge, transitions‑of‑care, 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 with measurable results.

Required skills

• Familiarity with HEDIS, Stars, PCR, TRC, TCM documentation.
• Understanding of ADT and HIE workflows.