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  • Transitional Care Clinician will be responsible for delivery of the Transitional Care Intervention (TCI) program.


  • Aims for this position will focus on reduction in hospital readmission rates by optimization of the Umpqua Health TCI program and interdepartmental collaboration with Umpqua Health Care Management services for members deemed “at risk” for readmission or inadequate access to primary care.
  • Conducting review of medical records to assess members for readmission risk.
  • Responsible to notify the Transitional Care clinical staff and/or leadership of care activities or trends, which could result in adverse effect for members.
  • In coordination with the hospital UR/Discharge Planner, collaborate on discharge planning for eligible members,
  • Participate in inpatient rounds as assigned and report any trends or provider issues.
  • Identifies any significant gaps in Transitions of Care planning.
  • Identify and reports cases appropriately for care coordination services to Transitional Care clinicians.
  • Identifies and reports under-utilization and over-utilization of medical services, delays in service or treatment and quality of care issues to Transitional Care supervisor.
  • Actively participates in internal quality and workflow enhancement projects, and other duties, as assigned.
  • Comply with organization’s internal policies and procedures, Code of Conduct, Compliance Plan, along with applicable Federal, State, and local regulations.
  • Other duties as assigned.

Job TitleTransitional Care Clinician (Other Positions Available)


  • Current Oregon license as Registered Nurse, Licensed Practical Nurse or certified Medical Assistant in good standing.
  • Knowledge of medical group and hospital operations.
  • Attention to detail and strong organizational skills.
  • Communicate effectively with physicians and staff at all levels in the organization.
  • Strong problem solving skills and results-oriented.
  • Strong project management skills and the ability to motivate a diverse staff and interdisciplinary teams.
  • Familiarity with the complex needs of a population with multiple medical, social and psychological obstacles to achieving and maintaining wellness and stability in the community.

Job Status: Full-Time

Hours: Depends on Employer

WageDepends on Employer

Location: Roseburg

How to Apply: Umpqua Health