Transition of Care Associate - Remote

CVS Health • Work At Home-Pennsylvania, PA

4d • $22 - $49 • Remote

About The Position

The Transition of Care Associate (also referred to in the posting as the Transition of Care Coach) coordinates care for members experiencing a significant change in health status that has led to an emergency department visit, inpatient admission, skilled nursing stay, or rehabilitative stay. The role supports seamless transitions to the next care setting and helps members achieve post-discharge goals through discharge planning, medication support, benefit education, clinical assistance, and coordination with providers and community resources.

The associate evaluates health and social indicators, identifies barriers to optimal health, applies strategies to reduce member risk, updates care plans when health or behavioral health status changes, and presents cases at multidisciplinary conferences. The role also coordinates post-discharge meal delivery, durable medical equipment, and timely physician follow-up. Transition of Care Associates review prior claims and use assessments or questionnaires to identify whether members may need referrals to clinical resources.

The position involves outreach calls and post-discharge questionnaires within required compliance timelines, use of utilization reports to help reduce emergency department use and 30-day readmissions, and follow-up with members from hospital admission through the care continuum until they can return to their prior level of functioning in the community. The associate facilitates interdisciplinary care team meetings to discuss service needs and support safe transitions.

Requirements

• At least 2 years of work experience.
• LPN/LVN license in good standing with no restrictions.
• Discharge planning experience.
• Advanced proficiency in Microsoft Word, Excel, and Outlook.
• Ability to multitask, prioritize, and adapt effectively in a fast-paced, changing environment while providing outstanding care.
• Effective verbal and written communication skills.
• Associate's degree required.

Nice To Haves

• Bilingual.
• Compact licensure.
• Bachelor's degree preferred.

Responsibilities

• Complete post-discharge questionnaires and outreach calls within required compliance-driven timelines.
• Provide comprehensive discharge planning and support seamless transitions to the next care setting.
• Ensure members have received or filled prescribed medications and understand how to take them.
• Educate members about benefits and provide clinical assistance to determine appropriate services and supports.
• Coordinate with primary care and specialty providers, including support related to prior authorizations, condition management, medication management, and community resources.
• Evaluate health and social indicators and identify barriers to optimal member health.
• Use discretion to apply strategies that reduce member risk.
• Present cases at multidisciplinary case conferences.
• Coordinate care with the care team to support member wellness within the limits of members’ conditions and self-management abilities.
• Coordinate post-discharge meal delivery, assist with securing durable medical equipment, and help ensure timely physician follow-up.
• Communicate payer and plan benefits, policies, and procedures to providers, members, and other personnel.
• Update care plans when a member’s condition or behavioral health status changes.
• Review prior claims to address potential impacts on case management and eligibility status.
• Use weekly and daily reporting to identify utilization and help reduce emergency department utilization and 30-day hospital readmissions.
• Follow members from inpatient admission, whether planned or unplanned, through the care continuum until they can return to their prior level of functioning in the community.
• Facilitate interdisciplinary care team meetings with Social Services, Care Management, primary care providers, and other key participants.

Benefits

• Medical coverage.
• Dental coverage.
• Vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs.
• Other resources, based on eligibility.
• Eligibility for a CVS Health bonus, commission, or short-term incentive program.

What This Job Offers

• Job Type: Full-time
• Education Level: Associate degree