Registered Nurse – Transition of Care

This is a fully remote position, open to applicants in Illinois.

📋 Description

• Conduct market-specific assessments post-discharge to pinpoint member requirements, focusing on Health Related Social Needs and Social Determinants of Health.

• Facilitate comprehensive discharge planning and assist with transitions between institutional and community environments.

• Confirm that members receive their medications and comprehend their usage.

• Identify suitable services and support, which include prior authorizations, provider coordination, condition management education, medication management, and community resources.

• Recognize barriers to optimal member health and implement strategies to mitigate member risk.

• Lead and manage Interdisciplinary Care Teams to formulate and execute Individualized Care Plans.

• Coordinate care with interdisciplinary teams to promote optimal wellness and self-management.

• Organize post-discharge meal delivery, secure durable medical equipment, and ensure timely follow-up with physicians.

• Provide education to members and caregivers regarding care plans, medications, and community resources.

• Clarify payer and plan benefits, policies, and procedures to providers, members, and personnel.

• Revise care plans when there are changes in conditions or behavioral health status.

• Analyze prior claims and assessments to determine case management, eligibility, and clinical resource needs.

• Conduct outreach cadence calls and post-discharge questionnaires within compliance timelines.

• Schedule follow-up appointments and perform medication reconciliation.

• Identify and resolve barriers such as transportation, housing, and access to medications.

• Utilize weekly and daily reporting to decrease emergency department usage and 30-day hospital readmissions.

• Monitor members from inpatient admission through the care continuum until they return to their previous community functioning.

• Facilitate interdisciplinary meetings involving Social Services, Care Management, PCPs, and other stakeholders.

• Ensure adherence to state and federal regulations, including NCQA standards.

⛳️ Requirements

• Active and unrestricted Registered Nurse (RN) License in Illinois.

• Minimum of 3 years of clinical practice experience.

• At least 1 year of experience in care coordination or working with high-risk populations.

• Proficient in Microsoft Office Suite, including Word, Excel, Outlook, OneNote, and Teams.

• Self-sufficient and confident working from home, utilizing tools for virtual collaboration and connection with teams.

• Access to a private, dedicated workspace to perform job duties effectively.

• Associate’s Degree in Nursing (REQUIRED).

• Familiarity with LTSS and HCBS options, chronic disease management, medication side effects, health equity and cultural competency, community-based services, and public benefits.

• Strong analytical and problem-solving capabilities.

• Effective communication, organizational, and interpersonal skills.

• Ability to work independently, multitask, prioritize, and adjust to a fast-paced, dynamic environment.

• Must have or be able to secure a direct/hardwired internet connection within 7 feet of the computer, with minimum speeds of 25 Mbps download and 3 Mbps upload.

• WiFi and satellite internet are not acceptable.

• Quiet, secure, private home workspace that complies with CVS Health and HIPAA guidelines.

• Must reside and work within the state and city of current residence.

• Must provide personal workspace furniture.

• Comfortable setting up and utilizing multiple monitors and navigating various applications.

• Proficient in using email, calendar invites, Teams messaging, and conducting virtual meetings.

• Experience with Microsoft Office 365 applications or similar Google Workspace tools.

• Ability to access secure systems such as VPN and EHR portals, lock computer screens, manage strong passwords, and identify suspicious emails or links.

• Capable of troubleshooting common technical issues independently.

• Willingness to acquire new skills.

• Bilingual candidates are preferred.

• Certified Case Manager certification is preferred.

• Bachelor’s Degree in Nursing is preferred.

🏝️ Benefits

• CVS Health bonus, commission, or short-term incentive program in addition to base salary.

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources supporting physical, emotional, and financial well-being.

• Company-provided equipment, including keyboard, monitor, computer, headset, etc.