The RN transition of care manager manages a patient's successful transition from hospital to home and is accountable for developing, implementing, and evaluating comprehensive transitional care interventions for high-risk medical and/or surgical patients. They are responsible for managing the post-acute care of high-risk patients who are at risk for poor health outcomes, frequent emergency room visits, hospital readmissions, and working with complex and varied patients and situations. They are responsible for completing outreach to patients within the MCO and ACO that are high-risk and require follow-up visits for health maintenance and care gap closure.