Transitional Care Management Nurse

Advocate Health and Hospitals Corporation • Mint Hill, NC

4d • Remote

About The Position

This is a remote work from home position requiring high-speed internet and that the candidate live within 1 hour of Mint Hill. It is a 0.5 FTE position covering every weekend from 0800 to 1830. The role involves conducting comprehensive clinical assessments of high-risk patients at discharge and throughout the 30-day transitional care period, identifying medical, psychosocial, and environmental risk factors. The nurse will develop, implement, and update individualized, patient-centered care plans, coordinate care, and facilitate communication among various healthcare providers and community resources. This position serves as the primary point of contact for patients and families, providing education on disease management, medications, and symptom monitoring. The nurse will manage a caseload of post-discharge patients, ensuring adherence to treatments and follow-up appointments. Collaboration with interdisciplinary teams, monitoring patient progress through various contact methods, and ensuring compliance with CMS Transitional Care Management guidelines are key responsibilities. The role also includes participation 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.

Nice To Haves

• ED/Triage/CM experience preferred.
• 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