Job Summary: The Transitional Care Operations Director is the operator of the health center's care transitions strategy. This leader executes standardized, high-performance workflows for Transitional Care Management with discharge follow-up, referral and hospital liaison processes, home-based care, and telehealth. The role drives measurable improvements in readmissions, emergency department utilization, medication reconciliation, follow-up visit completion, and patient experience, while ensuring operations align with Patient-Centered Medical Home standards, value-based contracts, and FQHC regulatory and payer requirements.
Position Impact
The Transitional Care Operations Director is a bold, results-driven leader who owns the entire care transitions and Transitional Care Management ecosystem across the organization. This role is accountable for building, scaling, and optimizing transitional care operations and Advanced navigation to reduce avoidable hospital use, close care gaps, and deliver seamless patient journeys from hospital to home and back into primary care.
Duties and Responsibilities: Strategic and Program Leadership - Own the vision and roadmap for transitional care and TCM across all sites and programs
- Set goals for readmissions, emergency department utilization, follow-up rates, and patient experience, and drive execution to meet or exceed them
- Build and continuously refine whole-person care pathways that integrate medical, behavioral health, pharmacy, and supportive services for high-risk and complex patients using advanced navigation pathways
- Align transitional care initiatives with organizational strategic priorities, value-based arrangements, and population health objectives
Operational Management - Design, implement, and standardize workflows for TCM visits, hospital discharge follow-up, referral management, and home-based care, including home visits, telehealth, and remote monitoring
- Lead and manage transitional care teams with clear metrics, accountability, and rapid performance feedback
- Ensure reliable communication and information transfer between hospitals, skilled nursing facilities, home health agencies, specialty providers, and primary care teams
- Partner with IT and analytics to optimize EHR work queues, alerts, registries, and dashboards that support real-time operational decisions
Clinical Integration and Quality - Collaborate with clinical leaders to create and enforce standardized protocols for high-risk transitions, including discharge planning and post-discharge follow-up
- Lead quality improvement efforts that directly impact readmissions, emergency department visits, adverse events, and timeliness of follow-up care
- Drive high-reliability processes for medication reconciliation and integration of pharmacy services into transitional care workflows
- Use data to identify care gaps, root causes, and opportunities, and move quickly from insight to action
Compliance, Billing, and Documentation - Ensure operational workflows support accurate, timely, and compliant billing for TCM and related services across all major payers
- Embed FQHC regulations, Patient-Centered Medical Home expectations, and payer requirements into daily practice, including required time frames, contact standards, and documentation elements
- Work with Revenue Cycle and Compliance to monitor documentation and coding, reduce denials, and maximize appropriate reimbursement
- Develop and maintain clear policies, procedures, and training tools that make compliance operationally simple and sustainable
External Partnerships and Network Development - Establish and manage strong relationships with hospitals, health plans, skilled nursing facilities, home health
Required Skills/Abilities: - Strong leadership and organizational skills with the ability to manage multiple priorities
- Excellent Microsoft Office computer skills
- High ethical standards
- Well-organized and self-directed
- Team player
- Ability to relate to people at all levels in the organization
- Great communication skills
- Consumer advocate for quality whole person care
- Ability to handle multiple projects at the same time and to prioritize assignments and responsibilities to ensure compliance with established deadlines and protocols
- Must be willing to travel between MyCHN sites
- Ability to exercise good judgement in evaluating situations and making decisions
Preferred Skills/Abilities: - Bilingual in English and Spanish
Required Education and Experience: - High school diploma or equivalent
- 5 to 7 years of experience in healthcare front office operations or patient services leadership
- Knowledge of medical terminology, insurance verification, and scheduling protocols
Preferred Education and Experience: - Certified or Registered Medical Assistant
Supervision Responsibilities: 
