Transition of Care – Registered Nurse

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

📋 Description

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

• Offer detailed discharge planning and facilitate transitions between institutional care and community settings.

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

• Identify suitable services and supports, including prior authorizations, provider coordination, educational resources for condition management, medication management, and community resources.

• Recognize and tackle barriers to achieving optimal member health.

• Implement strategies aimed at reducing member risk.

• Lead and coordinate Interdisciplinary Care Team meetings to formulate and execute Individualized Care Plans.

• Collaborate with interdisciplinary teams to promote optimal member wellness.

• Arrange for post-discharge meal delivery, acquire durable medical equipment, and ensure timely physician follow-ups.

• 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 staff.

• Revise care plans in response to changes in condition or behavioral health status.

• Analyze prior claims for potential effects on case management and eligibility.

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

• Schedule follow-up appointments and perform medication reconciliation.

• Utilize weekly and daily reporting to minimize emergency department visits and 30-day hospital readmissions.

• Support members throughout the continuum of care from inpatient admission until they return to previous community functioning.

• Organize care team meetings with Social Services, Care Management, Primary Care Providers (PCPs), and other stakeholders.

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

⛳️ Requirements

• Active and unrestricted Registered Nurse (RN) License in Illinois or a commitment to obtain one.

• 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.

• Comfortable working remotely and independently, utilizing virtual collaboration tools.

• Access to a private, dedicated workspace.

• Associate’s Degree in Nursing (mandatory).

• Certified Case Manager credential preferred.

• Preferred experience of 3+ years in Care Management, Discharge Planning, and/or Home Health Care Coordination.

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

• Bilingual candidates preferred.

• Strong analytical and problem-solving skills preferred.

• Excellent communication, organizational, and interpersonal skills preferred.

• Ability to work independently, manage multiple tasks, prioritize effectively, and adapt to a fast-paced environment preferred.

• Must adhere to state and federal regulations, including NCQA standards.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• CVS Health bonus, commission, or short-term incentive program.

• Comprehensive benefits package supporting physical, emotional, and financial well-being.

• Remote work from home.