Transitional Care Management Nurse

Advocate Health and Hospitals Corporation • Mint Hill, NC

1d • Remote

About The Position

This is a remote work from home position requiring high-speed internet and the ability to live within one hour of the Mint Hill location. The role is 0.5 FTE, working every Saturday & Sunday from 0800-1830. The Transitional Care Management Nurse conducts comprehensive clinical assessments of high-risk patients at discharge and throughout the 30-day transitional care period, identifying medical, psychosocial, and environmental risk factors. They develop, implement, and update individualized, patient-centered care plans addressing clinical needs, medication management, and follow-up care. This role coordinates care and facilitates communication among various healthcare providers and agencies, serving as the primary point of contact for patients and families. Responsibilities include managing a caseload of post-discharge patients, leading interdisciplinary rounds, monitoring patient progress through various contact methods, ensuring compliance with guidelines, and participating in quality improvement initiatives.

Requirements

• Bachelor of Science in Nursing (BSN) required.
• Active, unrestricted Registered Nurse (RN) license.
• Minimum of five years of clinical nursing experience in acute care, discharge planning, post‑acute care, or transitional care.
• Minimum of three years of experience providing care and patient education to complex populations, including heart failure, COPD, GI bleed, sepsis, or stroke.
• Advanced clinical expertise in complex patient management and transitional care.
• Strong care coordination, critical thinking, and clinical decision‑making skills.
• Demonstrated leadership in interdisciplinary collaboration and patient advocacy.
• Strong communication skills, including use of motivational interviewing techniques.
• Proficiency with electronic health records, care coordination tools, and telehealth platforms.
• Knowledge of regulatory requirements and reimbursement criteria related to transitional care.
• Strong organizational, analytical, and prioritization skills.
• Commitment to ethical practice, patient‑centered care, and continuous professional development.
• Primarily remote work environment with occasional on‑site meetings.
• Standard schedule is Monday through Friday, 8:00 a.m. – 4:30 p.m., with potential evening or weekend coverage as needed to support patient transitions and caseload requirements.

Nice To Haves

• Master of Science in Nursing or related field preferred.
• Preferred certifications include Medical‑Surgical RN (MEDSURG‑BC), Cardiac‑Vascular Nursing (CV‑BC), or Nursing Case Management (CMGT‑BC).
• Additional experience in transitional care or case management preferred.

Responsibilities

• Conduct comprehensive clinical assessments of high‑risk patients at discharge and throughout the 30‑day transitional care period, identifying medical, psychosocial, and environmental risk factors.
• Develop, implement, and continuously update individualized, patient‑centered care plans addressing clinical needs, medication management, and follow‑up care.
• Coordinate care and facilitate timely communication among inpatient providers, primary care, specialists, home health agencies, and community resources.
• Serve as the primary point of contact for patients and families, providing education on disease management, medications, symptom monitoring, and escalation protocols.
• Manage a caseload of post‑discharge patients and ensure completion of follow‑up appointments, home visits, and adherence to prescribed treatments.
• Lead and participate in interdisciplinary rounds and case conferences, collaborating with physicians, pharmacists, social workers, behavioral health providers, and nursing staff.
• Monitor patient progress through outreach visits, telehealth, and phone contacts, intervening promptly when clinical or psychosocial issues arise.
• Ensure compliance with CMS Transitional Care Management guidelines, Joint Commission standards, and organizational policies through accurate and timely documentation.
• Participate in quality improvement initiatives and identify opportunities to strengthen transitional care workflows and patient outcomes.
• Perform other duties and responsibilities as assigned.

Benefits

• Competitive compensation
• Generous retirement offerings
• Programs that invest in your career development
• Paid Time Off programs
• Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
• Flexible Spending Accounts for eligible health care and dependent care expenses
• Family benefits such as adoption assistance and paid parental leave
• Defined contribution retirement plans with employer match and other financial wellness programs
• Educational Assistance Program

What This Job Offers

• Job Type: Part-time
• Career Level: Mid Level