Transition of Care Registered Nurse - Field in Northern NJ

Position Summary

We’re building a world of health around every individual—shaping a more connected, convenient, and compassionate health experience. This role plays a vital part in helping members successfully transition from nursing facilities back into the community, managing incoming referrals, maintaining on‑site presence, and coordinating safe, timely discharges that promote independence and quality of life.

• Assess member readiness to return home, facilitating Interdisciplinary Team (IDT) meetings, and developing comprehensive, member‑centered transition plans of care.
• Manage incoming referrals for nursing facility transitions, maintaining a strong on‑site presence 2–3 days per week and building trusted relationships with facility staff and interdisciplinary teams.
• Coordinate safe, timely discharges that promote independence and quality of life, ensuring a monthly goal of three successful transitions.
• Conduct follow‑up visits, including NJ Choice Change in Condition assessment within 10 business days of discharge, and conduct significant change visits within 7 business days.
• Participate in workgroup meetings, sharing insights to improve processes, outcomes, and transition success.
• Engage in preventive care: schedule and confirm appointments, coordinate transportation, promote adherence to care plans.
• Implement strategies to reduce avoidable ED visits and hospital admissions through early intervention and education.
• Provide member education on in‑home safety, fall prevention, and medication adherence.
• Aspire to accompany members to medical appointments to support continuity and understanding of treatment plans.
• Leverage critical thinking and evidence‑based clinical criteria for contractual rebalancing goals.
• Work collaboratively with case managers to identify high‑risk members and implement interventions to prevent lapse or coordinate safe transition.

• Active, unrestricted RN license in the state of New Jersey.
• Minimum 2 years of clinical experience.
• Experience in managed care, discharge coordination, transition of care, home health, case management, or Medicaid.
• Reliable transportation; willing and able to travel up to 75% of time within assigned coverage area of New Jersey.
• Must reside in Northern New Jersey (Warren, Sussex, Morris, Passaic, Bergen, Essex, or Hudson Counties).
• Proficiency with computer systems, navigating multiple platforms.
• Associate Degree required; BSN preferred.
• Ability to work in a fast‑paced environment.

• 2 or more years clinical nursing experience in home health, case management, and/or discharge planning.

Typical pay range: $32.01 - $68.55, based on experience, education, geography and other factors. Eligible for bonus, commission, or short‑term incentive programs.

Full‑time position eligible for comprehensive benefits: medical, dental, vision, paid time off, retirement savings, wellness programs, and other resources.

Application window closes on 06/27/2026.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.