Transition of Care - Registered Nurse
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Job Description
Registered Nurse coordinating discharge planning and care transitions for CVS Health’s complex Medicare and Medicaid members. Reducing readmissions through individualized care plans, medication support, and interdisciplinary coordination.
Responsibilities:
- Complete market-specific post-discharge assessments to identify member needs, including health-related social needs and social determinants of health
- Provide comprehensive discharge planning and facilitate transitions between institutional and community settings
- Ensure members receive medications and understand how to take them
- Coordinate prior authorizations, PCP and specialty-provider coordination, condition-management education, medication management, and community resources
- Identify and address barriers to optimal member health
- Apply strategies to reduce member risk
- Lead and coordinate Interdisciplinary Care Teams to develop and implement Individualized Care Plans
- Coordinate care to support optimal wellness and self-management
- Coordinate post-discharge meal delivery, secure durable medical equipment, and support timely physician follow-up
- Educate members and caregivers on care plans, medications, and community resources
- Explain payer and plan benefits, policies, and procedures to providers, members, and personnel
- Update care plans following changes in condition or behavioral-health status
- Complete outreach calls and post-discharge questionnaires within compliance timelines
- Schedule follow-up appointments and complete medication reconciliation
- Use reporting to reduce emergency-department utilization and 30-day hospital readmissions
- Follow members from inpatient admission through the care continuum until return to prior community functioning
- Facilitate interdisciplinary meetings with Social Services, Care Management, PCPs, and other stakeholders
- Ensure compliance with state and federal regulations, including NCQA standards
Requirements:
- Active and unrestricted Registered Nurse (RN) License in Illinois
- Associate’s Degree in Nursing (REQUIRED)
- 3+ years of clinical practice experience
- 1+ year(s) of experience in care coordination or working with high-risk populations
- Proficient in Microsoft Office Suite, including Word, Excel, Outlook, OneNote, and Teams
- Confidence working at home and independently using virtual collaboration tools
- Access to a private, dedicated workspace
- Direct/hardwired internet connection within 7 feet of the modem/router
- Minimum internet speed of 25 Mbps download and 3 Mbps upload
- Quiet, secure, private designated home work location compliant with CVS Health and HIPAA guidelines
- Must work within the state and city where currently living
- Ability to use multiple monitors and navigate multiple applications
- Ability to use email, calendar invites, Teams messaging, and virtual meetings
- Experience with Microsoft Office 365 applications or similar tools such as Google Workspace
- Ability to access secure systems such as VPN and EHR portals
- Ability to manage strong passwords and recognize suspicious emails or links
- Ability to troubleshoot common technical issues independently
Benefits:
- CVS Health bonus, commission or short-term incentive program in addition to base pay
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources supporting physical, emotional, and financial well-being
- Company-provided equipment (keyboard, monitor, computer, headset, etc.)
- Remote work from home
- Benefits based on eligibility
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