Acute Care & Transitions Manager (RN or LPN)

Job description

**About Us** Greenbrook Medical is building the new standard in primary care. We deliver high-touch, relationship-based care through neighborhood clinics, grounded in a simple belief: every senior deserves the kind of care we would want for our own families. Our model prioritizes time with patients, strong care coordination, and a personalized approach that improves outcomes while lowering total cost of care. We take full accountability for patient outcomes and overall cost of care, aligning clinical excellence with disciplined execution. That commitment shows up in our results, including a patient Net Promoter Score of 91, compared to 32 for typical healthcare organizations. Rooted in Tampa Bay and partnered with Tampa General Hospital, we are entering an exciting phase of growth. Backed by strong unit economics, experienced operators, and a proven playbook, we are looking for builders and operators who want to help scale a healthcare platform designed to deliver better care, better coordination, and better outcomes for seniors. **About The Role** The moments immediately before and after a hospitalization are some of the most important moments in a patient's care. As our Acute Care & Transitions Manager, you'll own the day-to-day coordination of patients moving through acute care settings, from hospital and emergency department admission through SNF stays and successful transition back into the community. You'll monitor acute care utilization, build strong relationships with hospital and SNF partners, coordinate discharge plans, and ensure patients are connected back to their Greenbrook care team quickly and safely. This is a highly proactive, time-sensitive role. You'll be the person making sure that when a Greenbrook patient enters the hospital, we know about it, understand what is happening, communicate with the care team, and have a plan for what happens next. You'll also serve as a clinical resource for urgent patient needs and help Greenbrook prevent unnecessary ED utilization by ensuring patients have appropriate access to care when they need it. You'll work closely with Greenbrook physicians, Complex Case Managers, center managers, medical assistants, hospitalists, inpatient care managers, skilled nursing facilities, and specialists. You'll report to our VP, Market Medical Director and work alongside our broader care management team. **Location:** Greater Tampa Bay Area (travel between clinics, hospitals, and skilled nursing facilities required) **What You’ll Do** Own Acute Care & Hospital Transitions - Monitor hospital and emergency department admissions daily and proactively identify Greenbrook patients requiring intervention. - Establish timely communication with hospitalists, inpatient care managers, and other members of the acute care team. - Understand the reason for admission, clinical status, anticipated discharge needs, and barriers to a safe transition. - Coordinate discharge planning and ensure appropriate follow-up is scheduled with the Greenbrook care team. - Complete or coordinate timely post-discharge outreach and medication reconciliation. - Ensure critical discharge information, medications, follow-up needs, and care plans are communicated to the appropriate Greenbrook team members. - Identify patients requiring additional support and transition them to the Complex Case Manager or other appropriate resources. Coordinate SNF Transitions - Monitor Greenbrook patients admitted to skilled nursing facilities. - Establish relationships with SNF clinical teams and maintain visibility into patient progress. - Track anticipated discharge dates and proactively address barriers that may unnecessarily extend SNF stays. - Coordinate the patient's transition from SNF back to the Greenbrook clinic and community. - Ensure follow-up appointments, medication reconciliation, and other post-discharge needs are completed promptly. - Escalate complex or high-risk patients to the Complex Case Manager for ongoing longitudinal management. Prevent Avoidable Emergency Department Utilization - Serve as a clinical resource for patient triage and urgent needs. - Evaluate incoming patient concerns and guide patients toward the most appropriate level of care. - Support same-day access and Greenbrook's ER diversion protocols. - Coordinate with clinic teams and physicians to identify alternatives to unnecessary ED utilization. - Perform IV placement in the clinic when clinically appropriate and within scope. - Identify recurring acute care utilization patterns and share insights with physicians and care management leadership. Build Strong Acute Care Partnerships - Develop trusted relationships with hospitalists, inpatient care managers, SNF clinical teams, specialists, and other external care partners. - Establish reliable communication pathways with hospitals and SNFs throughout your market. Represent Greenbrook as a proactive and collaborative clinical partner. - Identify opportunities to improve communication, discharge planning, and transitions between Greenbrook and external facilities. - Help develop and improve Greenbrook's systems and workflows for managing acute care events and transitions. Drive Accountability for Transitions - Track patients through the acute care journey from admission through return to the community. - Maintain visibility into outstanding discharge and follow-up needs. - Use data to identify trends in hospitalizations, ED utilization, readmissions, and SNF utilization. - Identify breakdowns in transition workflows and recommend improvements. - Ensure no critical post-discharge action falls through the cracks. **What Success Looks Like** - Greenbrook is notified quickly when patients enter the hospital or ED. - Strong relationships and communication pathways exist with hospitals and SNFs throughout the market. - Patients receive timely and appropriate post-discharge follow-up. - Medication reconciliation and transition-of-care activities are completed reliably. - Avoidable ED utilization and hospital readmissions decrease. - SNF stays are actively monitored and unnecessary delays are reduced. - Patients transition smoothly from acute care back to their Greenbrook clinic and community. - Complex patients are appropriately handed off to the Complex Case Manager for ongoing management. - Physicians and clinic teams trust you to manage the acute care transition process and keep them informed. **About You** You bring: - Active RN or LPN license. - 3+ years of nursing, acute care, care management, or transitions of care experience. - Experience working with hospitals, emergency departments, skilled nursing facilities, or inpatient care teams. - Strong clinical judgment and patient triage skills. - Experience with transitions of care, discharge planning, or post-acute care coordination. - Experience in managed care, Medicare Advantage, or value-based primary care. - Strong organizational skills and ability to manage multiple time-sensitive patients and priorities. - Strong Excel skills and comfort using data to identify trends and opportunities. - A mindset grounded in our core values of Heart, Excellence, Accountability, Resilience, and Teamwork. You’ll stand out if you: - Have experience in hospital case management, utilization management, or transitions of care. - Have experience working directly with hospitalists, inpatient care managers, or SNFs. - Have experience supporting Medicare Advantage populations. - Have knowledge of local hospitals, SNFs, specialists, and community resources. - Have experience reducing avoidable ED visits, hospitalizations, or readmissions. - Thrive in fast-paced environments where priorities change quickly. - Are exceptionally organized, proactive, and known for following through. - Build trust quickly with physicians, nurses, hospital teams, patients, and external partners. - Are comfortable working independently and traveling throughout the market. - Are bilingual in Spanish. **Why You’ll Love Working Here** **Make An Impact Every Day** Be part of a mission-driven team transforming primary care for seniors. Your work directly supports better outcomes, better coordination, and better experiences for some of the most vulnerable patients in healthcare. **Work That Actually Matters** We’re not a volume-driven system, we’re accountable for outcomes. That means your work directly contributes to quality care, patient satisfaction, and meaningful improvements in how healthcare is delivered. **Build And Grow With Us** We’re building more than a company, we’re building careers. As we expand, you’ll have opportunities to grow your skills and take on new challenges. **Strong, Transparent Compensation & Benefits** - $100,000 base salary, based on experience and qualifications - Generous annual performance bonus - Health, dental, and vision insurance - Paid time off - 401(k) with company match We believe in fair, equitable pay that reflects your experience and impact. **Our Selection Process** Application → Initial interview → Skills/experience interview → Values interview → Clinic Visit + Case Study interview → References **Equal Employment Opportunity and Commitment to Diversity** At Greenbrook Medical, we believe the only way we accomplish our mission is by building the best team in healthcare. We do this through a culture of respect and belonging, ensuring our teammates feel cared for first and foremost. We will extend equal employment opportunity to all applicants without regard to age, race, ethnicity, sex, religion, sexual orientation, gender identity, socioeconomic background, disability status, military affiliation, pregnancy or any other status protected under federal, state and local laws. We encourage all who share our mission to apply. Greenbrook Medical will provide reasonable accommodations during the recruitment process. If you need additional accommodations or assistance, do not hesitate to contact our People team at [recruiting@greenbrookmedical.com](mailto:recruiting@greenbrookmedical.com).