Care Transitions Nurse Job at Advocate Aurora Health (Milwaukee)

Nurse Practitioner, Transitional Care

The Advanced Practice Provider, Transitions delivers high-touch, high-quality ca...

Location

United States , Indianapolis

Salary:

Not provided

CVS Health

Expiration Date

July 21, 2026

Requirements

Have an active, non-probationary state medical license, including US work authorization, if applicable
1+ years APN experience, preferably with a Medicare population
Experience in home-based care (as RN or APP) preferred
Flexibility to travel throughout service area
Electronic Medical Record experience
Computer skills: Ability to quickly navigate and use multiple computer programs to include, but not limited to: Gmail, MS Word or Google Docs, Excel or Google Sheets, etc.
Additional language proficiency in Spanish, Polish, Russian, or other languages spoken within the communities we serve preferred but not required

Job Responsibility

Provide post-discharge support according to defined pathways within the patient's home
Develop care plans and individualize goals of care with patient, their families, and their providers
Optimize and monitor clinical status, identify and address gaps in care, reconcile medications and address adherence challenges
Collaborate with Transitional Care Managers, home health, social workers, hospitals, SNFs, and specialists
Structure and prioritize scheduling based on clinical complexity for both new and routine patients
Recognize, diagnose, and manage both acute and chronic medical conditions in order to prevent destabilization and readmissions
Provide after-hours and weekend call support, shared with other in-state providers
Facilitate and conduct goals of care and advance care planning discussions with patients and families
Assess and evaluate family/caregiver needs and limitations
Teach patients, caregivers, and others about their health conditions

What we offer

Mission-focused career impacting change and measurably improving health outcomes for Medicare patients
Paid vacation, sick time, and investment/retirement 401K match options
Health insurance, vision, and dental benefits
Opportunities for leadership development and continuing education stipends
New centers and flexible work environments
Opportunities for high levels of responsibility and rapid advancement
Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
Paid time off
Flexible work schedules

Fulltime

Transitional Care Advanced Practice Provider (APP)

The Advanced Practice Provider, Transitions delivers high-touch, high-quality ca...

Location

United States , St. Louis, MO

Salary:

78000.00 - 168714.00 USD / Year

CVS Health

Expiration Date

March 16, 2026

Requirements

Have an active, non-probationary state medical license, including US work authorization, if applicable
1+ years APN experience, preferably with a Medicare population
Experience in home-based care (as RN or APP) preferred
Flexibility to travel throughout service area
Electronic Medical Record experience
Computer skills: Ability to quickly navigate and use multiple computer programs to include, but not limited to: Gmail, MS Word or Google Docs, Excel or Google Sheets, etc.
Additional language proficiency in Spanish, Polish, Russian, or other languages spoken within the communities we serve preferred but not required

Job Responsibility

Provide post-discharge support according to defined pathways within the patient's home
Develop care plans and individualize goals of care with patient, their families, and their providers
Optimize and monitor clinical status, identify and address gaps in care, reconcile medications and address adherence challenges
Collaborate with Transitional Care Managers, home health, social workers, hospitals, SNFs, and specialists
Structure and prioritize scheduling based on clinical complexity for both new and routine patients
Recognize, diagnose, and manage both acute and chronic medical conditions in order to prevent destabilization and readmissions
Provide after-hours and weekend call support, shared with other in state providers
Facilitate and conduct goals of care and advance care planning discussions with patients and families
Assess and evaluate family / caregiver needs and limitations
Teach patients, caregivers, and others about their health conditions

What we offer

Mission-focused career impacting change and measurably improving health outcomes for Medicare patients
Paid vacation, sick time, and investment/retirement 401K match options
Health insurance, vision, and dental benefits
Opportunities for leadership development and continuing education stipends
New centers and flexible work environments
Opportunities for high levels of responsibility and rapid advancement

Fulltime

Embedded Transitional Care Manager

The Embedded Transitional Care Manager - RN (TCM-RN) plays a critical role in en...

Location

United States , Indianapolis

Salary:

54095.00 - 116760.00 USD / Year

CVS Health

Expiration Date

Until further notice

Requirements

An active RN license within the state of practice in good standing
willingness to obtain cross-state licensure, as needed
Certified Case Manager (CCM) or equivalent case management certification required, or willingness to obtain within 12 months of hire
2+ years’ experience in transitional nursing, discharge planning, nursing case management, or home health
experience in utilization management preferred
knowledge of Medicare/Medicaid and NCQA regulatory transitions of care criteria
exceptional communication skills and customer service orientation
innovative and independent problem-solving skills
ability to monitor and evaluate opportunities for cost-effective care options with high-quality outcomes
Spanish-speaking preferred but not required

Job Responsibility

Manage patients through transitions of care, either face to face in the facility or telephonically
advocate for the patient throughout the care continuum
identify opportunities for workflow improvements and partnerships
maintain real-time records of patient transitions
engage with physicians, case managers, and hospitalists
coordinate follow-up care, medication reconciliation, and discharge planning
collaborate with internal stakeholders and regional leaders on transitions initiatives
participate in training, documentation, tracking, and quality assurance

What we offer

Mission-focused career
paid vacation and sick time
investment/retirement 401K match options
health insurance, vision, and dental benefits
affordable medical plan options
no-cost programs for health and wellness
tuition assistance
flexible schedules
family leave
dependent care resources

Fulltime

Dementia Consultant - Hospital to Community and Residential Care Transition

A rewarding opportunity to be involved in a Dementia Centre initiative looking t...

Location

Australia , Daw Park

Salary:

Not provided

HammondCare

Expiration Date

July 31, 2028

Requirements

Expertise in supporting people living with dementia
Experience in Australian residential aged care and or community aged care
Be relatable and able to share knowledge in a way that supports change at all levels
High level of negotiation, communication and relationship building skills
Excellent problem solving and decision-making skills
Ability to prioritise multiple tasks and meet deadlines
Excellent written and verbal communication skills
Excellent stakeholder management
A current Australian drivers licence and willingness to travel
Empathy and patience

Job Responsibility

Support families, caregivers and clinical staff to understand how dementia impacts each individual
Equip carers and clinicians to prevent and respond to behaviour changes through modelling, coaching, and development of resources including behaviour support planning
Be able to synthesise information, through observation and written documentation to provide recommendations that are relationship centred and informed by evidence based best practice
Develop reports that are contextualised to individual situations and people, that effect change on the ground and improve quality of life for people living with dementia
Undertake a range of assessments that help to understand the holistic experience of the person and their care network
Work in partnership with the broader Dementia Support Australia to build capability across the home and aged care sectors
Contribute to research, projects and programs and work innovatively to meet the changing needs of the sector
Work on other projects and assignments as required and in line with areas of skill, expertise and knowledge

What we offer

Market leading remuneration
Salary packaging
$15,900 annually for living expenses, plus up to $2,650 each year for entertainment benefits
Flexible hybrid work arrangements in a friendly workplace with an emphasis on work life balance
Additional training & career development opportunities
Leave benefits – purchased additional annual leave
Reward and Recognition Program
Fitness Passports: Full facility access can include gyms, group classes and pools for yourself and your family
Free independent and confidential counselling sessions and free wellbeing resources and webinars available through our Employee Assistance Program in multiple languages
Exclusive discounts at MyCar

Fulltime

Licensed Vocational Nurse Care Coordinator - Population Health

Provides care under the direct supervision of the Population Health Director of ...

Location

United States , Irving

Salary:

Not provided

CHRISTUS Health

Expiration Date

Until further notice

Requirements

LVN License in state of employment or compact

Job Responsibility

Manages a case load of 10,000-15,000 patients with identified gaps in care in collaboration with the Health Care Team
Works in collaboration with the PCMH Team in the design, implementation and evaluation of the PMH model as applicable
Works proactively to coordinate preventative/follow-up care for all patients receiving care from participating providers
Reviews patient medical record to identify care gaps
Schedules needed preventative services using evidenced based Physician approved protocols and documents the encounter
Fosters a Team approach by working collaboratively with the member, family, PCP and other members of the healthcare team to ensure coordination of services
Assists Nurse Navigators’ in performing transition of care outreach to discharged patients to schedule return visit with the PCP per guidelines
Employs knowledge of evidenced based guidelines to effectively communicate the importance of recommended procedures and testing
Facilitates a collaborative approach with care team for identification of and closure of care gaps
Utilizes educational and behavioral change strategies to promote patient collaboration with the care team

Fulltime

Rn - Transitional Care Navigator

Harrison's Hope Hospice is seeking an RN Transitional Care Navigator. This posit...

Location

United States , Meridian

Salary:

Not provided

Arcadia Home Care and Staffing - an Addus family company

Expiration Date

Until further notice

Requirements

Bachelor’s degree in marketing, business administration, or other related fields is preferred
Licensed as a registered nurse in the state of practice, a plus
Must possess the ability to make independent decisions when circumstances warrant
Must possess the ability to deal tactfully with patients, family members, visitors, agency personnel, and general public
Must be knowledgeable of quality assessment and assurance procedures
Valid driver’s license and proof of insurance is required

Job Responsibility

Collaboration with the Hospice Liaison team and Admissions team to increase public awareness of hospice and other services provided by the agency and to drive admissions for the placement of patients to meet expectations
Act as first point of contact for hospitals, health care facilities, and other sources regarding referrals
Seek networking opportunities to provide education and to develop relationships with new and existing referral sources
Identifying appropriate care and services to patient and family in accordance with attending physician and plan of care, as well as company policy and procedures

What we offer

Great culture and team atmosphere
Comprehensive benefits (medical, dental, vision, life/AD&D, disability), effective on the first of the month
401(k) retirement plan with a generous company match
Generous time off accruals
Paid holidays
Mileage reimbursement
Tuition Reimbursement
Employee Referral Program
Merit Increases
Employee Discount Programs

Transitional Care Navigator

Addus Home Care / JourneyCare Hospice is seeking a Hospice Transitional Care Nav...

Location

United States , Naperville

Salary:

82000.00 - 93000.00 USD / Year

Arcadia Home Care and Staffing - an Addus family company

Expiration Date

Until further notice

Requirements

Bachelor’s degree in marketing, business administration, or other related fields is preferred
Licensed as a registered nurse in the state of practice, preferred
Minimum of two years relevant experience
Must possess the ability to make independent decisions when circumstances warrant
Must possess the ability to deal tactfully with patients, family members, visitors, agency personnel, and public
Must be knowledgeable of quality assessment and assurance procedures
Valid driver’s license and proof of insurance is required

Job Responsibility

Serve as hospice clinical consultant and educator, acting as extensions of hospital and physician care team
Review hospital clinical documentation/EMR/HCHB, engage with patients and providers to build clinical patient profiles and clinical-admission-assessments and identify decline patterns
Consult with hospital care teams by sharing clinical profiles and educating on hospice appropriateness
Identify attending and consulting providers associated with referred patients – to provide patient assessment, eligibility and discharge education and awareness
Collaborate with field sales representatives to schedule and conduct consultative meetings with external care teams
Initiate and maintain care team workflows for: Patient information / clinical assessment and documentation, Consultation / education planning and delivery, External and internal meetings and preparations
Identify trends, needs, and partnership opportunities for earlier hospice engagement
Foster effective and trusted relationships with external care teams to improve patient outcomes and enhance end-of-life satisfaction
Communicate clearly and consistently with hospital leadership and care coordination teams
Effectively organize, track and prioritize high-value patient comprehensive reviews

What we offer

Great culture and team atmosphere
Comprehensive benefits (medical, dental, vision, life/AD&D, disability), effective on the first of the month
401(k) retirement plan with a generous company match
Generous time off accruals
Paid holidays
Mileage reimbursement
Tuition Reimbursement
Employee Referral Program
Merit Increases
Employee Discount Programs

Fulltime

Care Transitions Coordinator RN/LPN Clinical Sales

Are you looking for a rewarding career as a care transitions coordinator? If so,...

Location

United States , Rosedale

Salary:

85000.00 - 90000.00 USD / Year

Amedisys

Expiration Date

Until further notice

Requirements

At least one year of experience in a healthcare related business development/outreach role
Current RN or LPN license, specific to the state(s) you are assigned to work
Reliable transportation, current driver's license, and liability insurance
This role will travel 50% or more within the assigned territory

Job Responsibility

Educates health care professionals, patients, and families about home care services
Develops and maintains relationships with key referral sources, such as hospitals, nursing homes and physician offices to generate leads
Coordinates patient admissions with the team, including obtaining all required documentation to complete referral to admission process
Conducts on-site visits to assess patient needs and identify barriers to care
Keeps accurate records of patient interactions and referrals
Achieves admissions, product, and payor-mix goals
Meets short and long-term target account goals
Documents the minimum expectation of sales calls daily in CRM (including pre and post call notes)
Maintains a complete, up-to-date record of targeted referral sources in territory in CRM
Attends community events to promote Amedisys

What we offer

A full benefits package with choice of affordable PPO or HSA medical plans
Paid time off
Up to $1,000 in free healthcare services paid by Amedisys yearly, when enrolled in an Amedisys HSA medical plan
Up to $500 in wellness rewards for completing activities during the year
Mental health support, including up to five free counseling sessions per year through the Amedisys Employee Assistance program
401(k) with a company match
Family support with infertility treatment coverage, adoption reimbursement, paid parental and family caregiver leave
Fleet vehicle program (restrictions apply) and mileage reimbursement

Fulltime

Care Transitions Nurse

Advocate Aurora Health

Location:
United States , Milwaukee

Category:
Nursing

Contract Type:
Not provided

Salary:

Job Description:

Job Responsibility:

Requirements:

Additional Information:

Job Posted:
February 20, 2026

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Care Transitions Nurse

Advocate Aurora Health

Location:United States , Milwaukee

Category:Nursing

Contract Type:Not provided

Salary:

Job Description:

Job Responsibility:

Requirements:

Additional Information:

Job Posted:February 20, 2026

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