Transition of Care Registered Nurse - Field in Central NJ

CVS Health•Edison, NJ

1d•$32 - $69

About The Position

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary: This role plays a vital part in helping members successfully transition from nursing facilities back into the community. The position focuses on managing incoming referrals for nursing facility transitions, maintaining a strong on‑site presence, and coordinating safe, timely discharges that promote independence and quality of life. The individual will be embedded in assigned nursing facilities 2–3 days or more per week, based on member needs and acuity, building trusted relationships with facility staff and interdisciplinary teams. Responsibilities include assessing member readiness to return home, facilitating Interdisciplinary Team (IDT) meetings, and developing comprehensive, member‑centered transition plans of care. Rather than carrying a traditional caseload, this role is outcome-focused, with a monthly goal of successfully transitioning three members from nursing facilities back to the community. The position also requires community follow‑up, meeting members face‑to-face after discharge to complete a NJ Choice Change in Condition assessment within 10 business days of discharge. In addition, the role participates in workgroup meetings, contributing insights that help improve processes, outcomes, and overall transition success. This position is ideal for someone who thrives in a collaborative environment, values meaningful in‑person engagement, and is passionate about helping members return home safely and confidently. Additional Job Details: Candidate must utilize workflows, processes, and critical thinking to ensure member remains in community for 6 months post transition Actively engage in preventive care efforts by scheduling and confirming member appointments, coordinating transportation, and promoting adherence to care plans. Implement strategies to reduce avoidable emergency department visits and hospital admissions through early intervention and education. Provide enhanced member education on in-home safety measures, including fall prevention and medication adherence. When appropriate, accompany members to medical appointments to support care continuity and ensure understanding of treatment plans. Applies critical thinking, evidence-based clinical criteria to support contractual rebalancing goals: Support the Health Plan Rebalancing Initiative goal of successful transitions: Identify and assess members to transition from the Nursing Facility (NF) setting into the community Follow up on CM referrals and visit current NF members in-person twice a week as needed to complete the rebalancing events and assessments. Complete telephonic or in-person contact as appropriate to assess the home prior to discharge and identify any environmental supports needed to support transition (i.e. ramp, DME installation etc.).Conduct an in-person Significant Change Visit with member and Rep if applicable, within 7 business days of transition. Coordinate provision of services as needed, establish Plan of Care, and document all actions taken. Contact facility’s Business Office once a week to follow-up on member's census and coordinate with Social Services and CM to facilitate discharge. Work collaboratively with health plan case managers to identify high risk community members and implement appropriate interventions to prevent lapse or coordinate safe transition (Upon receiving referral) Drive enhanced value of health care to increase member satisfaction and retention, and drive new membership growth. Engage in building strong relationships that contribute towards member satisfaction and retention

Requirements

Active, unrestricted and good standing RN license in the state of New Jersey
Minimum 2 years of clinical experience
Experience in all or some of the following: Managed Care, Discharge coordination, Transition of care, Home Health, Case Management and Medicaid
Must possess reliable transportation and be willing and able to travel up to 75% of the time in the assigned coverage area of New Jersey.
Mileage is reimbursed per our company expense reimbursement policy
Must reside in Central New Jersey; Hunterdon, Middlesex, Mercer, Somerset and Monmouth Counties
Position requires proficiency with computer skills which includes navigating multiple systems
Ability to work in a fast-paced environment

Nice To Haves

2 or more years clinical nursing experience in home health, case management and/or discharge planning.
BSN preferred.

Responsibilities

Managing incoming referrals for nursing facility transitions
Maintaining a strong on‑site presence
Coordinating safe, timely discharges that promote independence and quality of life
Assessing member readiness to return home
Facilitating Interdisciplinary Team (IDT) meetings
Developing comprehensive, member‑centered transition plans of care
Community follow‑up, meeting members face‑to-face after discharge to complete a NJ Choice Change in Condition assessment within 10 business days of discharge
Participating in workgroup meetings, contributing insights that help improve processes, outcomes, and overall transition success
Utilize workflows, processes, and critical thinking to ensure member remains in community for 6 months post transition
Actively engage in preventive care efforts by scheduling and confirming member appointments, coordinating transportation, and promoting adherence to care plans.
Implement strategies to reduce avoidable emergency department visits and hospital admissions through early intervention and education.
Provide enhanced member education on in-home safety measures, including fall prevention and medication adherence.
When appropriate, accompany members to medical appointments to support care continuity and ensure understanding of treatment plans.
Identify and assess members to transition from the Nursing Facility (NF) setting into the community
Follow up on CM referrals and visit current NF members in-person twice a week as needed to complete the rebalancing events and assessments.
Complete telephonic or in-person contact as appropriate to assess the home prior to discharge and identify any environmental supports needed to support transition (i.e. ramp, DME installation etc.).
Conduct an in-person Significant Change Visit with member and Rep if applicable, within 7 business days of transition.
Coordinate provision of services as needed, establish Plan of Care, and document all actions taken.
Contact facility’s Business Office once a week to follow-up on member's census and coordinate with Social Services and CM to facilitate discharge.
Work collaboratively with health plan case managers to identify high risk community members and implement appropriate interventions to prevent lapse or coordinate safe transition (Upon receiving referral)
Drive enhanced value of health care to increase member satisfaction and retention, and drive new membership growth.
Engage in building strong relationships that contribute towards member satisfaction and retention

Benefits

This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families.
The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.
Additional details about available benefits are provided during the application process and on Benefits Moments.

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