RN - Transition of Care Nurse; Hybrid

Job Summary

Under the supervision of the Transition of Care Clinical Program Manager, the Transition of Care (TOC) Nurse is responsible for managing a member’s successful transition from an acute or post‑acute level of care to home and for developing, implementing, and evaluating comprehensive transitional care interventions for high‑risk medical and/or surgical members for Prominence Health. The TOC Nurse facilitates the post‑acute care of members at risk for poor health outcomes, frequent emergency department visits, and hospital readmissions.

The TOC nurse identifies hospitalized high‑risk, complex members for program enrollment and communicates with all entities involved in the care of the member to promote and maximize care coordination. Key aspects of the TOC Program protocols are based upon inpatient and post‑discharge workflows, including bedside visits, member and family education regarding disease states and self‑care, identification of member‑level concerns regarding discharge, and anticipation of potential gaps in care.

Upon member hospital or skilled nursing facility discharge, the post‑discharge workflow includes scheduled periodic telephonic follow‑up for 30 days and an in‑person visit when appropriate. The workflow focuses on medication reconciliation and adherence, quality‑of‑life and functional status management, management of acute and chronic disease states, identification and rectification of gaps in care, support of the member’s ability to perform self‑care, and coordination of post‑discharge appointments and services such as durable medical equipment and home health.

The TOC Nurse will adhere to the CMSA Standards of Practice for Case Management, refer and contribute to the development of the plan of care, and participate in efforts associated with the successful operation of the SNP CM program to ensure the model of care meets or exceeds regulatory and accreditation requirements.

Hybrid Friday‑Tuesday schedule with Saturday and Sunday required, in‑person visits on weekends. Wednesday and Thursday off.

• Loan Forgiveness Program
• Challenging and rewarding work environment
• Competitive compensation and generous paid time off
• Excellent medical, dental, vision, and prescription drug plans
• 401(k) with company match and discounted stock plan
• SoFi Student Loan Refinancing Program
• Career development opportunities within UHS and its 300+ subsidiaries
• More information available on the benefits website

Education

• Associate or Bachelor’s Degree in Nursing, required.

License & Certifications

• Active, unrestricted, current, and valid Registered Nurse license in the states of practice (Nevada, Texas, and/or Florida), required.
• Certified Case Manager (CCM), Case Management Nurse – Board Certified (CMGT‑BC), Accredited Case Manager – RN (ACM‑RN), or Certified Managed Care Nurse (CMCN), preferred.

Experience

• Minimum of three (3) years in clinical nursing practice, required.
• Minimum of three (3) years of Case Management/Transition of Care experience in a managed care outpatient or community environment, preferred.
• Recent working knowledge of Milliman Care Guidelines, preferred.
• Experience working with the Medicare and Medicaid population segment, preferred.
• Knowledge of Medicare/Medicaid processes and compliance standards, preferred.
• Ability to effectively communicate in English;
  Spanish (Texas and Florida markets), and/or French Creole, Tagalog (Florida market) preferred.

All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal‑opportunity employers and fully support recruitment, selection, placement, promotion, and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status, or any other characteristic protected by federal, state, or local laws.

We believe that diversity and inclusion among our teammates is critical to our success.