Clinicas del Camino Real, Inc. · 1 day ago
Transitional Care Manager
Camarillo, CA
Full-time
Hybrid
Entry, Mid Level
$105K/yr - $125K/yr
1+ years expClinicas del Camino Real, Inc. is seeking a Transitional Care Manager (TCM) to support their membership by performing care management duties across the continuum of care for post-discharge members. The role involves telephonic outreach, patient assessments, and coordination with care teams to ensure effective transitions and access to community resources.
DentalHealth CareMedicalMental Health
Hiring Manager
Leslie Ramos
Responsibilities
Transitional Care Manager (TCM) provides telephonic outreach to all patients that have been discharged from a hospital or Skilled Nursing Facility within 2 business days of discharge
TCM may also utilize other means of outreach communication such as Patient Portal, phone text, or letter as appropriate
The TCM provides patient assessment and support for treatment regimen adherence and medication management, education to patient and/or family members to support self-management and independent living and communicates with other members of the patient’s care team to ensure care coordination and safe transition back to community
The TCM schedules a face-to-face visit with the Primary Care Provider or Advanced Practitioner and assists with scheduling other specialists’ visits as indicated
The TCM identifies available community services and health resources and facilitates access to care and services available to patient/family when needed
TCM notifies PCP, via patient case or phone call, of any urgent patient needs
Accesses and navigates Health Plan or the hospital EMR systems to obtain daily patient discharge list or discharge notifications and patient medical record
Reviews hospital discharge list identifying those patients discharged to Skilled Nursing Facility/Rehab
Sends notification to SNFs of the CDCR patient admission and requests notification by SNF when patient is discharged
Performs patient outreach calls within the defined timeline (two call attempts within 2 business days) of hospital/SNF discharge
Performs telephonic assessment to assess member needs and collaborate with resources and provides education/support for treatment regimen adherence and medication management to support self-management and independent living
Identifies potential care gaps and makes referrals as appropriate
Identifies available community services and health resources and facilitates access to care and services available to patient/family when needed
Notifies Primary Care Provider/staff of any urgent needs or concerns
Schedules face-to-face visit with PCP/AP
Collects, documents, and maintains all member information and care management activities to ensure compliance with current state, federal, and third-party payer regulations
Makes referrals for Complex Case Management, Enhanced Case Management, or Basic Case Management
Provides feedback to leadership on opportunities to improve and enhance care and quality delivery for members in a cost-effective manner
Attends all required team/staff meetings
Performs other duties as assigned by people leader to meet business needs
Qualification
Required
Completion of accredited Registered Nurse (RN) program, or an accredited Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) Program
1-3 years in case management, disease management, managed care or medical or behavioral health settings
A valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation
Preferred
3-5 years in case management, disease management, managed care or medical or behavioral health settings
Bilingual in Spanish and English preferred
Must have reliable transportation, as may be required to rotate to various Health Centers as needed
Company
Clinicas del Camino Real, Inc.
Clinicas del Camino Real, Inc. has been providing quality primary and preventative health care services to the residents of Ventura County since 1971.
501-1000 employees
H1B Sponsorship
Clinicas del Camino Real, Inc. has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (7)
2024 (2)
2023 (9)
2022 (7)
2021 (9)
2020 (7)
Funding
Current Stage
Late StageTotal Funding
$2MKey Investors
Gold Coast Health Plan
2025-06-25Grant· $2M
Leadership Team
G
Gagan Pawar
Chief Executive Officer
Recent News
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