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Our Values

Respect | Belonging | Accountability | Transparency

Department

* This position will require 3 days in-office per week.

Job Summary

The Care Management Transition of Care Team Manager is a pivotal leadership role within the Denver Health Medical Plan driving excellence in the seamless transition of members from acute care settings (hospitals, emergency departments, skilled nursing facilities) to home, outpatient, or post-acute care. This role ensures coordinated, evidence-based care during high-risk transitions to reduce readmissions, improve outcomes, and align with value-based care models. As a leader, you will mentor clinical staff, optimize TOC protocols, and collaborate with providers to create a member-centered continuum of care. Core responsibilities include development, implementation and continuous refinement of TOC workflow. This role with lead a team of nurse care managers specializing in TOC providing coaching, performance feedback and quality assurance. Key metric monitoring includes timely post-discharge follow up and enrollment in the TOC program. Workflows are outcomes oriented, and work will prioritize identification of high-risk members, proactive coordination of care with inpatient teams and health plan utilization management to meet member needs.

Essential Functions:

• Transition of Care Leadership & Strategy:
  - Delegation of TOC nurse care managers caseloads providing supervision and oversight of KPIs for productivity and outcomes
  - Analysis of clinical data to identify gaps, cost-drivers and lead process improvements
  - Partner with hospital systems, ACOs and post-acute care providers to establish standardized communication pathways (15%)
• Clinical Coordination & Quality Improvement:
  - Oversee proactive identification of high-risk members (e.g., chronic conditions, frequent ED utilizers, at risk for readmissions) and implement mitigation strategies
  - Ensure timely post-discharge follow-up which may include appointment scheduling, program enrollment, coordination with home health, rehabilitation or social services and provide member education related to self-management and warning signs
  - Assist with root-cause analysis of readmissions and adverse events related to TOC failures
  - Monitor and report key metrics including: 30-day readmission rates, time-to-first follow up, member satisfaction and provider satisfaction (30%)
• Compliance & Regulatory Alignment:
  - Ensure all TOC activities comply with CMS requirements, MAC guidelines and plan-specific policies
  - Stay current with evolving TOC regulations and innovations to ensure compliance and enhance team practices
  - Support audits (internal/external) related to TOC processes and documentation (30%)
• Stakeholder Engagement:
  - Build and maintain strategic relationships with hospital discharge planners, care managers, emergency department leadership and post-acute care facilities
  - Be a spokesperson for TOC best practices and socialize health plan TOC and other care management programs and resources
  - Collaborate with utilization management, pharmacy and health outcomes teams to address barriers to care (25%)

Education:

• Associate's Degree Nursing required
• Bachelor's Degree Nursing preferred

Work Experience:

• 1-3 years Health plan or hospital-based care management required
• 1-3 years leading a team of nurses or care managers (supervisor or leadership experience mandatory) required

Licenses:

• APRN-Certified Nursing Administration - AONL - American Organization for Nursing Leadership required OR
• AMBRNBC-Ambulatory Care Certification RN - ANCC - American Nurses Credentialing Center required OR
• CCM-Certified Case Manager - ANSI - American National Standards Institute required

Knowledge, Skills and Abilities:

• Deep understanding of the safety net populations with complex care needs
• Skills navigating acute, post-acute and community-based resources to support transitions of care
• Proficiency reviewing clinical information from EHRs and care management software systems
• Familiarity with CMS regulations
• Facile data analytic skills and quality improvement (e.g., PDSA, root-cause analysis)
• Strong mentorship and team development capabilities
• Ability to collaborate with cross-functional teams on organizational initiatives with shared goals

Shift

Work Type

Salary

Benefits

At Denver Health, we take care of the people who take care of our community. Our benefits are built to support your life, your family, and your future - with generous paid time off, fully paid parental leave, exceptional retirement contributions, comprehensive health coverage, and nationally recognized well-being programs. We invest in your growth through tuition assistance, career advancement pathways, and professional development - while also offering meaningful financial advantages through loan forgiveness eligibility and employer contributions. When you join Denver Health, you’re joining a mission-driven organization that invests in you.

Here is a small list of our benefit programs:

• Paid time off starting at 28 days per year, inclusive of vacation, personal/sick, and 7 Holidays

• 100% paid parental leave up to 6 weeks

• Immediate eligibility for retirement plans with employer contribution up to 9.5%

• Generous medical, dental, vision plans in addition to employer paid disability and life insurance.

• Comprehensive well-being programs including on-site employee fitness center located on Denver Health main campus and nationally recognized RESTORE Center

• Free RTD EcoPass (public transportation)

• Childcare discount programs & exclusive perks on large brands, travel, and more

• Tuition reimbursement & assistance

• Education, coaching, and professional development opportunities through the Workforce Development Center (WFDC) that support internal career growth and advancement pathways

• Professional clinical advancement program & shared governance

• Public Service Loan Forgiveness (PSLF) eligible employer+ free student loan coaching and assistance navigating the PSLF program

• National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer

About Denver Health

Denver Health is an integrated, high-quality academic health care system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denver’s 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Mountain Poison & Drug Safety, the Public Health Institute at Denver Health, Denver Health Medical Plan and Denver Health Foundation.

As Colorado’s primary, and essential, safety-net health care system, Denver Health is a mission-driven organization that has provided millions in uncompensated care for the uninsured each year.

Located near downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.

Denver Health is an equal opportunity employer (EOE). We value the unique ideas, talents and contributions reflective of the needs of our community. All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made. Applicants will be considered until the position is filled.

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About Denver Health

Take your career to the next level at Denver Health, where we offer a robust benefits package and endless opportunities for growth. Denver Health is a nationally-ranked, locally-trusted, premier healthcare institution located in the heart of Denver, Colorado.Twenty-five percent of all Denver residents, or approximately 150,000 individuals, receive their health care here. We are known as an integrated health care system that encompasses multidisciplinary academic specialties, a community health system, a level I adult trauma center, pediatric emergency and urgent care center home to Denver Public Health and many of the nation's leaders in medicine.Denver Health is an Equal Opportunity Employer At Denver Health we pride ourselves on our commitment to diversity. Equal opportunity is a fundamental principle of Denver Health. As an equal opportunity employer, Denver Health is committed to recruit, hire, promote and administer all human resource actions in a non-discriminatory manner. Denver Health is committed to providing equal opportunities in all business practices and to all persons regardless of age, race, color, national origin, genetic information, religion, sex, pregnancy, disab...ility, sexual orientation, gender identity, gender expression, marital status or veteran status (collectively “protected status”). Denver Health strives to maintain a work environment that is free from unlawful harassment and discrimination and will not tolerate any such conduct by employees or directed at employees within the scope of their employment. Read the full Human Resources Employee Principles and Practices policy.

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