Job Summary: The Transition Case Manager (TCM) is responsible for leading the care transitions processes related to patients with health related social needs, identified high risk for readmission to post-acute level of care, ensuring effective coordination across the care continuum including the acute care setting, ambulatory and post-acute care settings, while assuming a strong role as liaison between Medical Staff, Case Managers, Nursing, Allied Health disciplines, hospital/clinic business/financial services, agencies across the continuum (internal and external) and payors, as well as, building sustainable care pathways that drive positive patient outcomes, reduces readmissions, decreases healthcare costs and optimizes the patient experience. In addition, the TCM assumes a leadership role in the identification and management of patients with catastrophic needs, health related social needs and expands collaboration with other service providers within the hospital and community exemplifying proactive, patient-oriented clinical practice that optimizes quality of care, utilization, effective cost, and patient experience.