Rn transition coordinator Job at Advocate Health Care (Charlotte)

Embedded Transitional Care Manager RN

Oak Street Health takes a team-based approach to providing outstanding patient c...

Location

United States , Rockford

Salary:

66575.00 - 142576.00 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
Advocate for the patient throughout the care continuum
Identify opportunities for improved program workflows
Maintain real-time and accurate records of patient status
Adhere to CMS, state specific and NCQA compliance criteria
Evaluate patient status post-ED visit or observation stay
Triage to determine appropriate follow up care
Engage directly with inpatient physicians, case managers, medical directors, and hospitalists
Coordinate with the Utilization Management team
Conduct structured clinical assessment to identify post-discharge needs

What we offer

Paid vacation, sick time, and investment/retirement 401K match options
Health insurance, vision, and dental benefits
Affordable medical plan options
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access

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

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

Rn transition coordinator - transition services

Responsible for coordinating with the medical team, Clinical Care Managers, and ...

Location

United States , Charlotte

Salary:

38.20 - 57.30 USD / Hour

Advocate Health Care

Expiration Date

Until further notice

Requirements

Graduate of an accredited school of nursing required
BSN preferred
Current RN license or temporary license as a Registered Nurse Petitioner in the state in which you work and reside
Minimum of three years nursing experience preferred
Prefer two years in acute health care inpatient setting
home health, managed care, hospice, or case management
Current driver's license

Job Responsibility

Functions as a liaison for patient/family in navigating the continuum of care
Assesses, plans, coordinates, and evaluates services of patients with the goal of equipping and empowering individuals and their families to easily assess resources and adopt healthy lifestyles that will increase their ability to remain healthy at home or in the least restrictive environment
Works closely with hospitals, clinics, health care facilities, and agency clinical and administrative personnel to ensure patient care is seamless, efficient, effective and appropriate to the individual
Interacts daily with patients, medical professionals, and the community to achieve continuity of care, coordination of medical services, and to document plans of care as related to home health care and hospice services
Makes on-site consultative, educational visits in the hospital to evaluate the appropriateness of the patient's admission to continuing care services
Able to complete needs assessment considering psychosocial, physical, economic, and health literacy factors
Uses interpersonal skills and excellent communication skills to establish a rapport with the patient and forecast and prioritize his/her needs
Receives referrals and orders from physicians, hospital, and other agencies
Acts as a resource for clinical personnel
Completes accurate and appropriate documentation, logs, and/or patient forms and records to ensure compliance with regulations, agency policy, payer requirements, and standards of care

What we offer

Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program

Fulltime

Rn nurse navigator

$10,000 Sign-On Bonus – Join Blue Ridge Care Today! Your neighbors need you. You...

Location

United States , Winchester

Salary:

74000.00 - 104000.00 USD / Year

Blue Ridge Hospice

Expiration Date

Until further notice

Requirements

Current Registered Nurse (RN) license
Minimum 2–3 years of clinical nursing experience (chronic disease management preferred—cardiology, pulmonology, endocrinology, rheumatology, or similar specialties)
Strong knowledge of chronic condition management and patient coaching strategies
Experience with care coordination and EMR documentation
Bachelor of Science in Nursing (BSN) preferred
Prior experience in Principal Care Management (PCM), Chronic Care Management (CCM), Case Management, or Population Health preferred
Certification in care coordination or chronic disease management (e.g., RN-BC in Care Coordination & Transition Management) preferred
Strong clinical judgment, organizational skills, and the ability to build meaningful relationships with patients and providers
A proactive, compassionate spirit ready to serve your community and improve life’s journey

Job Responsibility

Identify and enroll eligible patients into the PCM program and complete comprehensive initial assessments
Develop individualized, disease-specific care plans aligned with clinical guidelines and patient goals
Conduct monthly PCM interactions with accurate CMS-compliant time tracking and documentation
Monitor symptoms, treatment adherence, labs, and clinical changes—intervening early to prevent deterioration
Provide medication education, lifestyle coaching, and motivational support to improve self-management
Coordinate referrals, diagnostic testing, follow-up visits, and interdisciplinary communication
Address barriers to care including transportation, social determinants of health, and financial concerns
Track outcomes, engagement, and quality metrics to continuously improve chronic condition management
Participate in periodic call rotation and collaborate in quality improvement initiatives

What we offer

$10,000 Sign-On Bonus
Competitive Pay + performance rewards
Shift Differentials for evening and weekend shifts
PTO and Paid Volunteer Time
Comprehensive Health Benefits
Tuition Reimbursement & Scholarships
Peer Support & Mentorship
30% Thrift Shop Discount
Growth Opportunities through the Blue Ridge Care 2030 Strategic Plan

Fulltime

Rn Nurse Navigator

$10,000 Sign-On Bonus – Join Blue Ridge Care Today! Your neighbors need you. You...

Location

United States , Winchester

Salary:

74000.00 - 104000.00 USD / Year

Blue Ridge Hospice

Expiration Date

Until further notice

Requirements

Current Registered Nurse (RN) license
Minimum 2–3 years of clinical nursing experience (chronic disease management preferred—cardiology, pulmonology, endocrinology, rheumatology, or similar specialties)
Strong knowledge of chronic condition management and patient coaching strategies
Experience with care coordination and EMR documentation
Bachelor of Science in Nursing (BSN) preferred
Prior experience in Principal Care Management (PCM), Chronic Care Management (CCM), Case Management, or Population Health preferred
Certification in care coordination or chronic disease management (e.g., RN-BC in Care Coordination & Transition Management) preferred
Strong clinical judgment, organizational skills, and the ability to build meaningful relationships with patients and providers
A proactive, compassionate spirit ready to serve your community and improve life’s journey

Job Responsibility

Identify and enroll eligible patients into the PCM program and complete comprehensive initial assessments
Develop individualized, disease-specific care plans aligned with clinical guidelines and patient goals
Conduct monthly PCM interactions with accurate CMS-compliant time tracking and documentation
Monitor symptoms, treatment adherence, labs, and clinical changes—intervening early to prevent deterioration
Provide medication education, lifestyle coaching, and motivational support to improve self-management
Coordinate referrals, diagnostic testing, follow-up visits, and interdisciplinary communication
Address barriers to care including transportation, social determinants of health, and financial concerns
Track outcomes, engagement, and quality metrics to continuously improve chronic condition management
Participate in periodic call rotation and collaborate in quality improvement initiatives

What we offer

$10,000 Sign-On Bonus
Competitive Pay + performance rewards
Shift Differentials for evening and weekend shifts
PTO and Paid Volunteer Time
Comprehensive Health Benefits
Tuition Reimbursement & Scholarships
Peer Support & Mentorship
30% Thrift Shop Discount
Growth Opportunities through the Blue Ridge Care 2030 Strategic Plan

Fulltime

Director, RN Case Management

The Director, RN Case Management provides strategic and operational leadership f...

Location

United States , Denver, Colorado

Salary:

115700.00 - 150500.00 USD / Year

InnovAge

Expiration Date

Until further notice

Requirements

Bachelor’s degree in Nursing (BSN)
Current state-issued Registered Nurse (RN) license
5+ years of experience in acute care coordination, case management, or discharge planning
2+ years of leadership or supervisory experience in a clinical setting
Demonstrated success in performance management, operational execution, and cross-functional collaboration
Experience in quality improvement, compliance adherence, or care coordination oversight

Job Responsibility

Leads, develops, and supports RN Case Managers, including recruitment, onboarding, coaching, and performance management
Establishes division-wide workflows, standards, and best practices for acute and post-acute care coordination
Partners with the VP of Nursing Operations and clinical leadership to implement staffing strategies, workload balancing, and coverage expectations for case management services
Oversees daily operational execution of case management functions, ensuring timely coordination, documentation, and communication across care teams
Ensures RNs receive training and ongoing development to maintain clinical competency in transitional care and utilization management
Oversees the experience of participants during hospitalization and post-acute stays, ensuring high-quality transitions and strong communication
Responds to escalated participant concerns in coordination with Center Directors, providers, and Quality teams
Ensures RN Case Managers collaborate effectively with participants, families, caregivers, and IDT members to support person-centered care plans
Monitors service KPIs and drives improvements in communication, responsiveness, and participant satisfaction during transitional care periods
Ensures division performance aligns with quality metrics related to readmissions, skilled days, length of stay, and transition-of-care outcomes

What we offer

medical/dental/vision insurance
short and long-term disability
life insurance and AD&D
supplemental life insurance
flexible spending accounts
401(k) savings
paid time off
company-paid holidays

Fulltime

RN Transition PICU

As our RN Transition Fellow, you will provide professional nursing care to patie...

Location

United States , Northridge

Salary:

52.90 - 75.30 USD / Hour

American Nursing Care

Expiration Date

Until further notice

Requirements

Graduate of Accredited RN school of Nursing
Minimum 2 years of RN experience in an acute care setting, upon hire
Registered Nurse: CA, upon hire
Basic Life Support - CPR, upon hire
Advanced Cardiac Life Support, upon hire
Pediatric Advanced Life Support, upon hire
Fire Safety, within 90 Days

Job Responsibility

Provide professional nursing care to patients of all ages, adhering to individual needs, physician orders, Hospital policy, and nursing standards
Assume responsibility for directing and coordinating care team members, focusing on individualized quality patient care
Collaborate with the healthcare team to implement comprehensive patient care plans
Participate in direct patient care activities, including assessment, medication administration, documentation, and patient education across diverse patient populations
Adhere to established Hospital/departmental policies and procedures
Apply clinical knowledge and expertise for coordinating patient care by regularly planning and evaluating the care of patients
Establish and maintain professional and collaborative relationships with other staff members, physicians, patients, patient family members, and the public
Demonstrate effective nursing judgement and a working knowledge of the nursing process
Provide guidance to interdisciplinary team members by supervising nursing interventions and assigning related tasks
Provide leadership by establishing priorities and coordinating nursing care

What we offer

Health/dental/vision
FSA
Matching retirement plans
Paid time off
Tuition assistance
Adoption assistance

Fulltime

Rn transition coordinator

Advocate Health Care

Location:
United States , Charlotte

Category:
Nursing

Contract Type:
Not provided

Salary:

Job Description:

Job Responsibility:

Requirements:

Nice to have:

Additional Information:

Job Posted:
February 11, 2026

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Job Description:

Job Responsibility:

Requirements:

Nice to have:

Additional Information:

Job Posted:February 11, 2026

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