Transitions of Care Management Pharmcist (REMOTE)

Job Summary The Transitions of Care Management Pharmacist will serve as a key clinical member of the Transitions of Care Management (TCM) team, supporting patients during the critical 30-day post-discharge period. This role focuses on high-quality medication reconciliation, clinical assessments, care coordination, and comprehensive patient education to reduce readmissions and strengthen continuity of care. In addition to TCM-specific responsibilities, the pharmacist will also deliver care management services, including disease education, medication education, ongoing risk assessment, and coordination across providers and community resources. The ideal candidate excels in medication safety, patient engagement, and interdisciplinary collaboration. Responsibilities • Perform post-discharge medication reconciliation, verifying discharge instructions, outpatient medication lists, and patient-reported use. • Identify discrepancies, duplications, drug interactions, contraindications, and therapy gaps, and escalate concerns appropriately. • Conduct structured TCM assessments to evaluate symptoms, treatment changes, functional status, and social/clinical risk factors. • Support scheduling of the TCM follow-up visit with the patient's provider and ensure all follow-up tasks are completed. • Document all interventions in the EHR in alignment with CMS TCM requirements and internal policies. • Participate in TCM team huddles to review ADT notifications, prioritize high-risk patients, and coordinate cross-team actions. • Monitor patients for early signs of deterioration and escalate to clinicians when needed. • Deliver disease-state education for chronic conditions such as diabetes, hypertension, COPD, CHF, CKD, and others relevant to the patient population. • Provide medication education, including purpose, dosing, administration, side effects, adherence strategies, and lifestyle considerations. • Assess patient-specific barriers, including social determinants of health, and coordinate interventions accordingly. Requirements • Active, unrestricted Pennsylvania Pharmacist License (RPh or PharmD). • PharmD strongly preferred. • 2+ years of clinical experience in ambulatory care, acute care, medication reconciliation, transitions of care, or care management. • Strong knowledge of chronic disease guidelines, medication safety principles, and patient counseling. • Experience with EHR systems (Epic, NextGen, or comparable). • Familiarity with CMS TCM requirements preferred. • Core Competencies • Advanced medication reconciliation and therapeutic review skills Work Environment • Remote work environment requiring HIPAA-compliant workspace • Timely response to ADT discharge alerts and TCM workflows • Flexible scheduling may be required based on patient discharge patterns • Collaboration with a multidisciplinary team across multiple clinics and providers • Strong clinical reasoning and risk stratification capabilities • Excellent communication and patient engagement skills • High accuracy in documentation and adherence to regulatory standards • Ability to operate independently and manage multiple patient cases simultaneously • Patient-centered, empathetic approach to care Job Types: Full-time, Part-time, Contract Application Question(s): • What's your availability to start if hired? • What is the minimum hourly rate you'll accept for this job? Education: • Doctorate (Preferred) Experience: • Transitions of Care Management: 1 year (Required) • Remote Patient Care: 1 year (Preferred) • Disease education: 2 years (Required) License/Certification: • PA Pharmacist license (Required) Work Location: Remote Apply tot his job