RN - Transition of Care Nurse; Hybrid

Responsibilities

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 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.

Inpatient/ SNF workflow includes visiting members at the bedside, member and family education regarding disease states and self‑care, identification of member‑level concerns regarding discharge, and anticipation of potential gaps in care. The encounters are designed to educate members/caregivers surrounding their post‑discharge health care needs and to empower them to play an active and informed role in managing their care post‑discharge.

Upon member hospital/SNF discharge, the post‑discharge workflow includes a scheduled periodic telephonic follow‑up for 30 days and an in‑person visit, when appropriate. This includes a focus on medication reconciliation and adherence, management of member’s quality of life and functionality, management of both acute and chronic disease states, identification and rectifying gaps in care, support of member’s ability to perform self‑cares, coordination of post‑discharge appointments and services (durable medical equipment, home health), and coordination of care across the care continuum.

The TOC Nurse will adhere to the CMSA Standards of Practice for Case Management and contributes to the development of the plan of care of members in Care Management. The position also participates in efforts associated with the successful operation of the SNP CM program and ensuring that the model of care meets regulatory and accreditation requirements for CMS, state Medicaid offices, and NCQA.

Hybrid Friday–Tuesday (Sat/Sun required, in‑person visits on weekends). Wed/Thu 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

Education: Associate or Bachelor’s Degree in Nursing (required).

License &

Certifications:

Active, unrestricted, current, and valid RN license in Nevada, Texas and/or Florida (required).

Preferred certifications:
Certified Case Manager (CCM), Certified Management Nurse – Board Certified (CMGT-BC), Accredited Case Manager – RN (ACM-RN), or Certified Managed Care Nurse (CMCN).

Experience:

• Minimum of three years in clinical nursing practice (required).
• Minimum of three 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 Medicare and Medicaid populations (preferred).
• Knowledge of Medicare/Medicaid processes and compliance standards (preferred).
• Ability to communicate effectively in English (required). Preferred Spanish, French Creole, and/or Tagalog (fluency depends on state of licensure and employment location).

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 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.