About Avail Health

Avail Health is a Nurse Practitioner–founded organization dedicated to removing barriers to care, access, and meaningful clinical work for Medicare-age individuals. We combine thoughtful technology, strong operational infrastructure, and deep respect for the patient–provider relationship to enable nurse-led virtual and mobile care models. As a fast-growing organization, we are building durable clinical infrastructure to support innovative care programs across multiple states, with a focus on improving outcomes for complex and underserved senior populations.

Role Summary

The Senior Manager, RN – Care Transitions is a frontline leadership role responsible for supporting the day-to-day execution of Avail Health’s Care Transitions Program in partnership with hospital teams and community stakeholders.

This role serves as the primary on-site presence for Avail Health within the hospital environment, helping to identify eligible patients, coordinate transitions of care, and support patient engagement following hospital discharge.

The Senior Manager will act as the local team leader for the care transitions team, supporting coordination of team activities and limited people management responsibilities while working closely with the senior leadership team, who maintain accountability for overall program strategy and clinical oversight.

A central component of this role is building strong partnerships with hospital leadership and frontline teams, serving as the face of Avail Health for both hospital stakeholders and patients entering the program.

The ideal candidate brings strong clinical assessment and critical thinking skills, particularly in evaluating patient risk and determining appropriate program engagement for complex Medicare-aged populations transitioning from hospital to home.

Reports to: VP of Care Delivery
Location: This position is primarily in-person and must be located within the geographic region of Rockville, Maryland, or within a reasonable commuting distance.

Work Environment: The role requires primarily in-person presence Monday through Friday within the hospital environment, participating in daily care coordination activities with hospital teams, including interdisciplinary huddles and care planning discussions.

In addition to hospital-based work, the role will include mobile clinical engagement with patients following discharge, including in-home visits as well as telephonic or virtual interactions when clinically appropriate. At program launch, mobile visit volume is expected to be limited, with responsibility increasing as the program scales. The role will also provide coverage and support for team RNs, and participation in mobile visits is an ongoing expectation of the position.

Limited remote work may occur for administrative, coordination, or leadership activities when not required on-site. Remote work requires a reliable high-speed internet connection and a dedicated, HIPAA-compliant workspace to ensure the security and confidentiality of patient information and organizational communications.

This role may also include occasional participation in an on-call rotation to support clinical questions from care team members outside of standard business hours. The structure and frequency of this coverage will evolve as the program scales.

Key Responsibilities

Hospital Partnership & Customer Success

• Serve as the primary on-site representative of Avail Health within the hospital environment, building strong relationships with hospital leadership, care management teams, and frontline clinical staff.
• Participate in hospital coordination activities including daily huddles, rounds, and care planning discussions to identify patients eligible for the Care Transitions Program.
• Support effective collaboration and warm handoffs between hospital teams and Avail Health to ensure smooth transitions from hospital to home.
• Represent Avail Health professionally and help ensure a positive partnership experience for hospital stakeholders.

Patient Identification & Program Enrollment

• Review hospital discharge lists and clinical documentation to identify patients eligible for the Care Transitions Program.
• Conduct patient outreach, assessments, and enrollment discussions with eligible patients and caregivers.
• Apply strong clinical judgment to assess patient complexity and risk factors, supporting appropriate prioritization and engagement within the program.
• Coordinate with hospital teams to facilitate timely program enrollment and continuity of care following discharge.

Team Leadership & Program Execution

• Serve as the local team leader for the Care Transitions care team, helping coordinate day-to-day team activities and patient workflows.
• Provide limited people management for clinical and community-based staff during the early stages of program launch.
• Collaborate closely with the senior leadership team to support team operations, workflow management, and operational coordination.
• Execute program workflows and care coordination processes established by leadership while providing frontline insights that help inform ongoing program improvement.
• As the program scales, additional operational leadership roles will be introduced to support team growth and operational infrastructure.

Care Coordination & Cross-Program Navigation

• Support coordination of care for patients transitioning from hospital to home across both medical and behavioral health populations.
• Facilitate referrals into appropriate hospital programs, community resources, and Avail Health care programs when clinically appropriate.
• Help ensure patients and caregivers understand and successfully navigate post-discharge care plans.

Technology & Program Infrastructure

• Utilize Avail Health’s technology platforms and tools to support patient identification, care coordination, and program tracking.
• Partner with hospital teams to support adoption of program tools, including customized dashboards and reporting used to track program engagement and outcomes.
• Serve as a knowledgeable frontline resource for hospital stakeholders using Avail technology platforms, helping address day-to-day questions and ensuring effective use of program tools.
• Collaborate with Avail’s technology and operations teams to provide feedback that helps refine tools and workflows as the program evolves.

Qualifications

Required:

• Active, unrestricted Maryland Registered Nurse (RN) license in good standing.
• Current Basic Life Support (BLS) certification.
• Minimum 5+ years of clinical RN experience with some prior mobile nursing experience, providing care to patients where they reside.
• Experience supporting post-hospital transitions of care, discharge planning, or complex care coordination.
• Minimum 2+ years of experience supervising or coordinating clinical staff or care teams.
• Strong clinical assessment and critical thinking skills managing complex patient populations.
• Excellent interpersonal and communication skills with the ability to build strong relationships with hospital teams and patients.
• Ability to operate effectively in a new program environment with evolving workflows and processes.

Preferred:

• Experience in hospital care management or discharge planning environments, transitions of care (TOC), transitional care management (TCM) or hospital readmission reduction programs.
• Emergency Department (ED) triage experience is highly preferred.
• Experience delivering home-based care through home health, hospice, or mobile care programs.
• Experience working with Medicare-aged populations with complex medical or behavioral health needs.
• Experience supporting clinical workflows, program implementation, or new care model launches.

What Success Looks Like

Success in this role will include the ability to:

• Build strong, trusted relationships with hospital teams and serve as an effective on-site program partner.
• Identify and enroll appropriate patients through strong clinical assessment and patient engagement.
• Coordinate the local care transitions team effectively during program launch.
• Ensure consistent execution of program workflows and care coordination processes.
• Contribute to improved patient transitions from hospital to home and reductions in avoidable hospital utilization.
• Provide actionable frontline insights that help inform ongoing program refinement.
• A positive, collaborative team culture aligned with Avail Health’s values.

Compensation & Benefits

• Total Salary: $110,000 – $126,500 annually, inclusive of base salary plus a 10% geographic market adjustment for the Montgomery County metropolitan region, commensurate with experience.
• Performance Bonus: quarterly bonus up to 2.5% of base salary (up to 10% annually) based on individual and program performance metrics.
• Annual Compensation Review: up to 5% of base salary, based on performance and organizational factors.
• Benefits Package: medical, dental, and vision insurance, subject to plan terms and eligibility requirements.
• Paid Time Off: 3 weeks annually, accrued per pay period.
• Holidays: 8 paid company holidays plus 1 floating holiday per calendar year.
• Retirement: 401(k) retirement plan with a 2% employer match, subject to plan terms and eligibility requirements.

Pay: $110,000.00 - $126,500.00 per year

Benefits:

• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Application Question(s):

• Please describe your experience supporting patients transitioning from hospital to home. Include examples of how you have assessed patient risk, prioritized follow-up, or made triage decisions (e.g., ED, discharge planning, or care management settings).
• Describe your experience leading or coordinating a clinical team. How have you supported team operations, guided workflows, or ensured effective patient care delivery in a fast-paced or evolving environment?
• This role requires working as an external partner with hospital leadership and frontline teams to support discharge planning, while also engaging directly with patients to assess eligibility and enroll them into the program. Please describe your experience collaborating with hospital teams in this type of partnership setting, and how you have built trust while coordinating care and engaging patients or families in care decisions or program participation.

Experience:

• RN: 5 years (Required)

License/Certification:

• RN License (Required)

Work Location: On the road