Transition of Care - Registered Nurse

CVS Health • Work At Home-Illinois, IL

1d • $66,575 - $142,576 • Remote

About The Position

The Transition of Care Case Manager (TOC CM) supports high-risk, medically complex, and vulnerable members enrolled in HIDE/FIDE SNP and other Medicaid waiver programs. The role helps ensure safe, effective transitions across care settings, including after emergency department visits, inpatient admissions, or stays in skilled nursing or rehabilitative facilities. Through person-centered planning and timely interventions, the TOC CM coordinates care, supports the development and implementation of care plans, facilitates communication among interdisciplinary teams, and helps members and families ensure necessary care and services are in place after discharge. The position aims to reduce readmissions, promote health equity, and improve health outcomes.

This role works with members, caregivers, providers, community organizations, and interdisciplinary care teams to address clinical and social needs across the care continuum. Work includes post-discharge assessments, discharge planning, medication reconciliation and education, follow-up scheduling, referral to clinical and community resources, and ongoing care-plan updates. The TOC CM also uses utilization reporting and prior claims information to support care management and eligibility review, and follows members from hospital admission through the care continuum until they can return to their prior level of functioning in the community.

This is a full-time work-from-home position. Employees must work from within the state and city where they currently live and maintain a quiet, secure, private home workspace that meets CVS Health and HIPAA guidelines. The role requires a direct wired internet connection with specified minimum speeds; Wi-Fi and satellite internet are not permitted. The company provides equipment, while the employee supplies workspace furniture.

Requirements

• Active and unrestricted Registered Nurse (RN) license in Illinois.
• At least 3 years of clinical practice experience.
• At least 1 year of experience in care coordination or working with high-risk populations.
• Proficiency with Microsoft Office Suite, including Word, Excel, Outlook, OneNote, and Teams.
• Ability to work from home as an independent thinker and use tools to collaborate and connect with teams virtually.
• Access to a private, dedicated workspace suitable for meeting the position’s requirements.
• Associate’s degree in Nursing.
• Ability to obtain and maintain a direct, hardwired internet connection to a modem/router within 7 feet of the computer, with at least 25 Mbps download and 3 Mbps upload; Wi-Fi and satellite internet are not permitted.
• A quiet, secure, private, organized home work location that is free from distractions, complies with CVS Health and HIPAA guidelines, and allows uninterrupted work during work hours.
• Work from within the state and city where the employee has confirmed they currently live.
• Ability to provide workspace furniture, such as a desk or standing desk, and remain at a desk for extended periods.
• Comfort setting up and using multiple monitors and navigating multiple applications simultaneously.
• Ability to use digital communication channels such as email, calendar invites, Teams messaging, and virtual meetings.
• Experience with Microsoft Office 365 applications or similar tools such as Google Workspace.
• Ability to access secure systems such as VPNs and EHR portals, secure devices and passwords, lock a screen when unattended, and recognize suspicious emails or links.
• Ability to resolve common technical issues independently and contact IT for issues that cannot be resolved.
• Openness to learning new skills as the workplace environment evolves.

Nice To Haves

• Certified Case Manager.
• At least 3 years of care management, discharge planning, and/or home health care coordination experience.
• Working knowledge of LTSS and HCBS options, chronic disease management, medication side effects, health equity, cultural competency, community-based services, and public benefits.
• Excellent analytical and problem-solving skills.
• Effective communication, organizational, and interpersonal skills.
• Ability to work independently, multitask, prioritize, and adapt to a fast-paced changing environment while providing outstanding care.
• Bilingual.
• Bachelor’s degree in Nursing.

Responsibilities

• Complete market-specific post-discharge assessments to identify member needs, including health-related social needs and social determinants of health.
• Provide comprehensive discharge planning and facilitate transitions between institutional and community settings, supporting continuity and quality of care.
• Ensure members have received or filled prescribed medications and understand how to take them.
• Provide clinical assistance to determine appropriate services and supports, including prior authorizations, coordination with primary care and specialty providers, condition-management education, medication management, and community resources.
• Identify and address barriers to optimal member health and apply strategies to reduce member risk.
• Lead and coordinate Interdisciplinary Care Teams to develop and implement individualized care plans.
• Coordinate care with the care team to support member wellness within the limits of the member’s conditions and ability to self-manage.
• Coordinate post-discharge meal delivery, assist with securing durable medical equipment, and help ensure timely physician follow-up.
• Educate members and caregivers about care plans, medications, and available community resources as needed.
• Explain payer and plan benefits, policies, and procedures to providers, members, and other key personnel.
• Update care plans when a member’s condition or behavioral health status changes.
• Complete outreach calls and post-discharge questionnaires within required compliance timelines.
• Schedule follow-up appointments and ensure medication reconciliation is completed.
• Address barriers to care such as transportation, housing, and access to medications.
• Use daily and weekly reporting to identify utilization and help reduce emergency department use and 30-day hospital readmissions.
• Follow members identified as inpatient through the subsequent 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 to discuss service needs and support safe transitions.
• Comply with state and federal regulations, including NCQA standards.
• Review prior claims to identify potential impacts on current case management and eligibility status.

Benefits

• Medical coverage.
• Dental coverage.
• Vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs.
• Other resources to support colleagues’ and families’ physical, emotional, and financial well-being, based on eligibility.
• Eligibility for a CVS Health bonus, commission, or short-term incentive program in addition to base pay.

What This Job Offers

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