Transition Care Manager

Location: Remote and field-based in the Central Region of Virginia, including Richmond, Glen Allen, Dinwiddie, Colonial Heights, Chester, and Henrico. Must reside in the Central Region of Virginia and travel to the VCU area at least three times per week. The role involves 50–75% field interactions and occasional meetings at the Glen Allen office. Working hours are Monday–Friday, 8:00 a.m.–5:00 p.m. Eastern Time.

Salary: $59,300–$80,900 per year, plus eligibility for a bonus incentive plan.

Company

hirify.global is a U.S. healthcare and insurance company serving Medicare and Medicaid members, families, individuals, and communities.

What you will do

• Assess member needs and coordinate individualized care plans during transitions between hospitals, rehabilitation facilities, custodial settings, and home- and community-based care.
• Support transitions across Virginia Medicaid programs to prevent unnecessary readmissions, emergency department visits, custodial placements, and adverse outcomes.
• Coordinate with primary care managers, providers, discharge planners, families, social workers, housing specialists, and other internal and external stakeholders.
• Arrange follow-up care, resources, authorizations, utilization management information, and clinical documentation.
• Participate in interdisciplinary care team meetings and care planning activities.
• Conduct telephonic and in-person meetings with members and healthcare professionals throughout the assigned region.

Requirements

• One of the following: an active, unrestricted Virginia RN license; an active, unrestricted Virginia LPN license; or a bachelor’s degree in social work, psychology, counseling, gerontology, nursing, or health and human services.
• At least two years of experience in healthcare and/or case management, including at least one year working directly with adults or pediatric populations at risk for chronic medical conditions and high social needs.
• Intermediate to advanced computer skills with Microsoft Word, Excel, Outlook, electronic medical records, and other healthcare information systems.
• Strong communication, interpersonal, critical-thinking, organizational, written, verbal, and problem-solving skills.
• Ability to manage competing priorities in a fast-paced environment and build rapport with members, providers, and stakeholders.
• Valid state driver’s license and personal vehicle liability insurance are required. The role is patient-facing and requires participation in hirify.global’s tuberculosis screening program.

Nice to have

• Master’s degree or applicable license in social work, psychology, counseling, gerontology, nursing, or health and human services.
• Experience with nursing home diversion, long-term care case management, Medicare and Medicaid recipients, or geriatric populations.
• Experience with electronic case-note documentation, health promotion, coaching, wellness, and community health or social service agencies.
• Bilingual or multilingual communication skills, including English/Spanish, Arabic, Vietnamese, Amharic, Urdu, or another language.

Culture & Benefits

• Combination of remote work and field-based services in inpatient and community settings.
• Full-time schedule of 40 hours per week with occasional travel to hirify.global offices for training or meetings.
• Medical, dental, and vision coverage; 401(k) retirement savings plan; paid time off and holidays.
• Paid parental and caregiver leave, short- and long-term disability coverage, and life insurance.
• Dedicated home workspace and internet service with at least 25 Mbps download and 10 Mbps upload speeds are required for remote work.

Hiring process

• Applicants selected for the role must complete hirify.global’s tuberculosis screening requirements.
• Applicants claiming proficiency in a language other than English may be required to complete the Interagency Language Rating assessment.