Care Transitions Utilization LPN
About The Position
Vitae Health Systems is seeking an experienced Care Transitions Utilization Nurse (LPN) to support patients during transitions out of post-acute care. Working alongside embedded nurse practitioners who facilitate discharge planning in the facility, the role provides telephonic outreach and follow-up for residents transferred to an emergency department or hospital, and for residents discharged from a skilled nursing facility to the community or another post-acute setting. The focus is on safe, well-coordinated transitions and reducing avoidable utilization. This is a hybrid role, with one day per week in the Park Ridge, Illinois office. The position reports directly to the Executive Director of Value-Based Care Clinical Operations. The nurse reviews acute-care events, conducts post-discharge outreach and triage, coordinates follow-up services, escalates concerns, maintains review data, and contributes to quality improvement and program development. Vitae Health Systems, founded in 2018 and headquartered in Chicago, Illinois, provides behavioral health, internal medicine, and podiatry services to residents of skilled nursing and assisted living facilities. It operates in more than 10 states and is rapidly expanding.
Requirements
- Active, unrestricted LPN license in Illinois, or eligibility for a compact license as applicable; perform responsibilities within the scope of the license and escalate as required.
- Five or more years of skilled nursing facility experience in a leadership or advanced role, such as ADON, unit manager, shift supervisor, or MDS coordinator.
- Working knowledge of SNF operations, Part A skilled stays, change-in-condition management, care planning, facility discharge processes, and SBAR communication methods.
- Hands-on QAPI experience, including root cause analysis, performance improvement projects, and data-driven follow-up.
- Demonstrated clinical judgment and comfort with telephone assessment and triage.
- Strong documentation, organization, and follow-through, with the ability to independently manage a high-volume workflow.
- Proficiency with EMR systems, spreadsheets, and dropdown-based review tools.
- Ability to work in a primarily computer- and phone-based environment, including prolonged sitting and extended phone use, while managing multiple competing priorities.
- Ability to travel periodically to partner facilities.
Nice To Haves
- MDS or RAC-CT certification or equivalent experience.
- Experience with ACO, value-based care, or care transitions programs, including ACO REACH or LEAD.
- Experience with ADT feeds and population health dashboards.
- Familiarity with goals-of-care and advance care planning conversations.
- Experience working with nurse practitioners in long-term care.
- Telephone triage or case management experience.
Responsibilities
- Identify emergency department visits and hospital admissions through ADT feeds and nurse practitioner notifications; conduct a structured review of each event and document key details and barriers.
- Determine the circumstances surrounding each event and discharge through chart review and provider discussion.
- Escalate cases to clinical leadership when defined triggers are met.
- Conduct telephone outreach following discharge to the community or another post-acute setting, building on the discharge plan developed by the embedded nurse practitioner.
- Confirm by telephone that patients are connected to appropriate ongoing care, including a community primary care provider where applicable, and have necessary follow-up care, medications, and resources.
- Coordinate with facility staff, community providers, and caregivers to close care gaps; escalate patients who cannot be connected or show early signs of decline.
- Perform telephone assessment and triage using approved protocols to distinguish emergent from non-emergent needs and direct patients to appropriate resources.
- Document each encounter and use SBAR to escalate to a nurse practitioner, registered nurse, or physician when a call falls outside protocol or clinical judgment requires it.
- Maintain accurate review data and prepare trend reports for Clinical Operations; identify discharge patterns and support case-based learning and focused deep-dive reviews.
- Apply QAPI methods to design, test, and track performance improvement projects, and report results to leadership.
- Partner with embedded nurse practitioners, facility nursing leadership, and Vitae VBC and Clinical Operations teams.
- Contribute to the development and revision of standard operating procedures as the program matures.
Benefits
- Competitive salary and benefits package.
- Opportunity to play a meaningful role in advancing value-based care for a high-need Medicare population.
- Opportunity to help build clinical programs and SOPs as the care transitions program matures.
- Collaborative and supportive work environment.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
