Care Transitions Utilization RN

Vitae Health Systems • Park Ridge, IL

3d • Hybrid

About The Position

Vitae Health Systems is seeking an experienced Care Transitions Utilization Nurse (RN) to manage patient needs during the transition out of the post-acute setting. Working alongside embedded nurse practitioners who facilitate discharge planning while patients are in the facility, this role provides telephonic outreach and follow-up for residents who transfer to the emergency department or hospital, as well as 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 role reports directly to the Executive Director of Value-Based Care Clinical Operations. The position involves a primarily computer- and phone-based work environment, including prolonged sitting and extended phone use, and periodic travel to partner facilities.

Requirements

• Active, unrestricted RN license in Illinois, or eligibility for a compact license as applicable.
• 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 manage a high-volume workflow independently.
• 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; periodic travel to partner facilities.
• Responsibilities must be performed within the scope of the nurse’s license, with escalation as required.

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 NP notifications; complete 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 telephonic outreach following discharge to the community or another post-acute setting, building on the discharge plan developed in-house by the embedded NP.
• Confirm by telephone that each patient is connected to appropriate ongoing care, including a community primary care provider where applicable, and has 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 who show early signs of decline.
• Perform telephone assessment and triage using approved protocols to distinguish emergent from non-emergent needs and direct patients to the appropriate resource.
• Document each encounter and use SBAR to escalate to an NP, RN, or physician when a call falls outside protocol or clinical judgment requires escalation.
• Maintain accurate review data and prepare trend reports for Clinical Operations; identify patterns in discharges 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 NPs, facility nursing leadership, and Vitae VBC and Clinical Operations teams; contribute to SOP development and revision 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.
• Be part of a rapidly growing organization with a commitment to excellence in healthcare.
• Help build clinical programs and SOPs as the care transitions program matures.
• Collaborative and supportive work environment.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: No Education Listed