Nurse Case Manager - Transition Of Care

UnitedHealth Group•Draper, UT

2d•$72,800 - $130,000•Remote

About The Position

The Transition of Care Registered Nurse is a telephonic role responsible for coordinating and managing care for members transitioning from observation, inpatient, skilled nursing, and other post-acute settings. The RN works with patients, caregivers, providers, Community Health Workers, and interdisciplinary teams to support safe transitions, address barriers to recovery, reduce avoidable hospital readmissions and emergency department utilization, and improve health outcomes. The position is remote for candidates who live in Utah and hold an active, unrestricted Utah RN license. Employees working remotely must adhere to UnitedHealth Group’s Telecommuter Policy. The role involves managing a caseload, conducting clinical assessments, developing and monitoring individualized care plans, coordinating follow-up and services, and maintaining compliant documentation. The RN also participates in care coordination, performance improvement, and population health initiatives.

Requirements

Current, unrestricted Registered Nurse (RN) license in Utah.
At least 3 years of clinical nursing experience, preferably in acute care, care management, case management, utilization management, discharge planning, or transitional care.
Experience in managed care, Medicare Advantage, value-based care, care management, or population health environments.
Case management knowledge and ability to independently assess member needs, develop care plans, prioritize interventions, and manage complex cases with minimal supervision.
Solid clinical assessment, critical thinking, problem-solving, and decision-making skills.
Excellent written, verbal, and interpersonal communication skills.
Ability to collaborate with providers, hospitals, skilled nursing facilities, Community Health Workers, and interdisciplinary care teams.
Proficiency with electronic medical records, case management systems, and Microsoft Office applications.
Valid, unrestricted driver’s license, reliable transportation, current automobile insurance, and acceptable driving record.
Must live in Utah and possess an active, unrestricted Utah RN license.

Nice To Haves

Bachelor’s degree in nursing (BSN).
Case Management Certification (CCM, ACM-RN, or equivalent).
Experience supporting transitions of care, readmission prevention, post-acute care management, or emergency department utilization programs.
Knowledge of community resources and social determinants of health.

Responsibilities

Assess, develop, implement, and monitor individualized care plans for discharged acute care patients and high-risk Medicare Advantage patients.
Manage a caseload and conduct comprehensive clinical assessments to identify medical, functional, psychosocial, and environmental factors affecting recovery and health outcomes.
Conduct timely outreach to eligible patients following hospitalization, emergency department visits, or post-acute care stays according to organizational standards.
Evaluate discharge plans and address barriers to recovery, treatment adherence, or successful transition to the community.
Perform medication reconciliation and identify medication-related concerns requiring intervention or provider follow-up.
Engage patients and caregivers in care planning, provide education, and promote self-management.
Coordinate care among patients’ healthcare settings and providers, including primary care providers, specialists, hospitals, skilled nursing facilities, home health agencies, and community resources.
Collaborate with Community Health Workers and interdisciplinary team members to address social determinants of health and other non-clinical barriers.
Facilitate timely primary care, specialty care, and post-discharge follow-up appointments when indicated.
Monitor patient progress during the transition period and modify interventions as needed.
Identify patients at risk for avoidable emergency department utilization, hospital readmissions, or adverse outcomes and implement appropriate interventions.
Communicate and collaborate with patients, caregivers, providers, and interdisciplinary teams to ensure continuity of care.
Maintain accurate, timely, and complete documentation in accordance with organizational, regulatory, and accreditation requirements.
Follow applicable policies, procedures, HIPAA regulations, and quality standards.
Participate in performance improvement, care coordination, and population health initiatives to improve member outcomes and reduce healthcare utilization.
Perform other duties as assigned.
Meet outreach, engagement, assessment, follow-up coordination, productivity, quality, documentation, and member-outcome performance indicators.