Transition of Care II, RN

Job Details

Job Location:

Arcadia Office - Arcadia, CA 91007

Position Type:
Full Time Salary Range: $81,500.00 - $ Salary This position operates on a hybrid work schedule. This position will require 3 days onsite at the Monrovia or Huntington Beach office.

Are you ready to make a lasting impact and transform the healthcare space? We are one of Southern California’s fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth.

Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members’ culture and values.

We’reon a mission! Our rapid growth reflects our commitment to making healthcare accessible for underserved communities.

At Clever Care,you’llhavethe opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation.

The Transitions of Care Registered Nurse II (TOC RN II) serves as an experienced clinical care coordinator responsible for managing members with moderate to highly complex medical, behavioral, and psychosocial needs during transitions across the continuum of care. In addition to providing comprehensive transitions of care services, the TOC RN II functions as a clinical resource and mentor to nursing staff, supports quality improvement initiatives, and assists leadership in promoting evidence-based practices, regulatory compliance, and operational excellence.

The TOC RN II independently manages a complex caseload, collaborates with interdisciplinary teams to resolve barriers to care, identifies opportunities to improve member outcomes, and contributes to organizational initiatives that support CMS compliance, NCQA accreditation, HEDIS and Star Ratings performance, and health equity.

• Perform comprehensive clinical assessments for members experiencing complex transitions of care following inpatient admissions, emergency department visits, skilled nursing facility stays, rehabilitation services, and other qualifying events.
• Independently manage a complex caseload requiring advanced clinical assessment, critical thinking, and interdisciplinary care coordination.
• Develop, implement, evaluate, and revise individualized transition care plans based on member needs, clinical priorities, evidence-based guidelines, and member goals.
• Complete medication reconciliation, identify complex medication-related concerns, collaborate with providers and pharmacists, and recommend interventions that promote medication safety and adherence.
• Coordinate services across hospitals, physician practices, skilled nursing facilities, behavioral health providers, home health agencies, pharmacies, hospice, palliative care, and community-based organizations.
• Identify members at high risk for readmission, adverse clinical outcomes, or care fragmentation and implement advanced care coordination strategies.
• Serve as a clinical resource for Transitions of Care Registered Nurse I staff by providing guidance on clinical decision‑making, documentation standards, care planning, and complex case management.
• Mentor newly hired nurses through clinical coaching, knowledge sharing, and support of departmental orientation activities.
• Participate in interdisciplinary care team (ICT) meetings and provide clinical recommendations that support safe, effective, and member‑centered care.
• Collaborate with Medical Directors, Utilization Management, Complex Case Management, Social Work, Pharmacy, Behavioral Health, Quality Improvement, and Provider Relations to resolve complex…