Transitional Care Management

Advocate Health and Hospitals Corporation•Elm Grove, WI

4d•Remote

About The Position

This is a part-time, fully remote position within Advocate Aurora Health Corporate - WI Transitional Care. The role requires a WI or IL RN license and involves weekend work, with hours from 0900-1930, and occasional holiday coverage. The primary focus is on managing post-discharge patients to ensure a smooth transition and positive health outcomes.

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.
High speed Internet, and WI or IL RN license required.

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

Compensation Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training
Premium pay such as shift, on call, and more based on a teammate's job
Incentive pay for select positions
Opportunity for annual increases based on performance
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