Rn - Transitional Care Navigator Job at Arcadia Home Care and Staffing

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

Transitional Care Advanced Practice Provider

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

Location

United States , Rockford

Salary:

87035.00 - 206206.00 USD / Year

CVS Health

Expiration Date

May 16, 2026

Requirements

Genuine passion for reaching vulnerable patients
strong clinical skills focused on older adults with complex disease states
comfort navigating visits in patient homes
demonstrated ability to collaborate effectively in a team setting
willingness to learn and be accountable for visit documentation and workflows
excellent communication, follow-up, teamwork, and problem-solving skills
desire to be a part of a fast-paced, innovative, quality-driven organization
have an active, non-probationary state medical license, including US work authorization
1+ years APN experience, preferably with a Medicare population
experience in home-based care (as RN or APP) preferred

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
benefit solutions that address the different needs and preferences of colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility

Fulltime

RN Care Manager

Inpatient Care Managers are Registered Nurses who independently assure patients ...

Location

United States , Salem

Salary:

52.52 - 80.11 USD / Year

Kaiser Permanente

Expiration Date

Until further notice

Requirements

Minimum of two years combine RN experience in the following areas: Med/Surg (hospital acute care)
ICU (hospital acute care)
Emergency Department
Home Health
Skilled Nursing Facilities
Hospice
Long Term Acute Care
Inpatient Rehab
Utilization Management
Successful completion of an RN program by date of hire

Job Responsibility

Independently assure patients are admitted to the correct level of care for accurate billing and reimbursement
Provide quality, cost effective clinical coordination/care management in acute care and emergency care settings
Manage patients with routine and complex transition planning needs by: independently assessing needs, developing and implementing plans of care for transitions across care settings
Serve as expert consultants and educators for physicians and other health care team members for discharge and transitional care, coordination of internal and community resources
Support the evaluation and improvement of systems of care to support the optimal utilization of health care resources, while maintaining quality of patient care
Assume primary accountability for anticipating, assessing, developing, implementing, documenting, advising, and communicating a safe transition plan of care for patients with complex care needs
Coordinates post-discharge patient care needs to assure the timely and effective discharge of routine and complex patients from the hospital setting
Independently and proactively completes and documents patient assessments which are thorough, timely, age appropriate, and reflect psychosocial support systems, care needs, health plan benefits, level of care determinations for hospitalized patients
Coordinates and communicates with patients, families, and the health care team to develop mutually agreeable plans of care that optimize the use of resources to support the particular needs of individual patients
Facilitates resolution of issues which present barriers to safe transfers through the use of patient/team care conferences to assure the efficient transition to a lower level of care and to assure the patient/family receives the right care at the right time so that quality and utilization of resources are simultaneously enhanced

What we offer

Medical, Vision & Dental
Retirement Plans
Tuition Reimbursement
Supportive Teams & Resources
Career Growth & Development

Parttime

New

Registered Nurse Navigator Population Health

The RN Navigator in Population Health is responsible for coordinating and managi...

Location

United States , Irving

Salary:

Not provided

CHRISTUS Health

Expiration Date

Until further notice

Requirements

Bachelor’s Degree in Nursing preferred
3 years of clinical experience required
2 years of case management experience required
Experience working in a primary care value-based care organization is required
Knowledge of population health management principles is required
RN license in the state of employment or compact is required
One of the following certifications is required within 2 years of hire: Certified Case Manager (CCM) by CCMC or Nursing Case Management Certification (CMGT-BC) by ANCC
Must have strong clinical assessment skills
Must have excellent communication and interpersonal skills
Must be able to work independently and as part of a team

Job Responsibility

Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders
Care Coordination of Complex/Chronic conditions: Manages and coordinates care for patients with chronic conditions, complex medical needs, and assists with Discharge Planning: Helps plan and coordinate the discharge process for members leaving hospitals or long-term care facilities, ensuring a smooth transition to home or another care setting
Care Coordination - Transitions of Care: Outreach to patients that qualify for Transitions of Care (IP Discharge) and ensure they understand their medications, educate patients on managing their conditions and knowing when to seek help, stressing the importance of scheduling and attending follow up appointments, and teaching them to recognize the signs that their condition might be worsening
Patient Assessment: Conduct comprehensive assessments to identify patient needs, barriers to care, and social determinants of health
Care Planning: Develop and implement individualized care plans based on patient assessments, clinical guidelines, and patient preferences. Focuses on reducing preventable admissions, readmissions, and preventable ED visits by supporting discharge planning to the next level of care and educating patients about the appropriate setting for care
Advocacy: Serve as an advocate for patients or clients, helping them to navigate the healthcare system, understand their treatment options, and access the services they require
Collaboration: Work closely with healthcare providers, social workers, and community resources to ensure a holistic approach to patient care
Monitoring and Evaluation: Track and communicate to PCPs and specialty care providers any significant changes to members' concerns, along with any updates on members’ status
Documentation: Maintain accurate and timely documentation of patient interactions, care plans, and outcomes in the electronic health record (EHR) system
Quality Improvement: Participate in quality improvement initiatives to enhance patient care and population health outcomes

Fulltime

New

Ambulatory RN Navigator, Surgical Oncology GI

Provides continuity of care by ensuring smooth transitions between care settings...

Location

United States , Winston Salem

Salary:

41.10 - 61.65 USD / Hour

Advocate Aurora Health

Expiration Date

Until further notice

Requirements

Registered Nurse license issued by the state in which the team member practices
Bachelor's degree in nursing
Typically requires 5 years of experience in nursing that includes performing nursing assessments, care plan development, and educating patients
Working knowledge of the components of quality and acute patient care needs
Maintains clinical expertise to effectively manage physical, emotional, psychosocial and spiritual needs of patients throughout the care continuum
Excellent analytical and interpersonal communication skills necessary to negotiate with families, patient, physicians, and third-party payers
Demonstrated ability to work well with physicians and other professionals in a direct and positive manner
Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served
Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures

Job Responsibility

Provides continuity of care by ensuring smooth transitions between care settings
Develops a relationship with patient and their multidisciplinary team to facilitate and/or navigate through subsequent treatment and follow-up to reflect continuity of care
Completes a nursing assessment to identify the patient's individualized needs and collaborates with multidisciplinary team and other departments to develop an interdisciplinary plan of care
Supports the patient and family by providing education, addressing psychosocial needs, advocating, providing continuity of care and identifying barriers to care
Navigates patients and family members throughout the diagnosis, treatment and follow-up of the patient throughout the continuum of care
Provides expert clinical advice to the multidisciplinary team in designing collaborative teaching plans/programs and in planning/providing patient/family education and discharge planning including wellness and health maintenance within designated specialty
Coordinates timely, seamless, evidenced based care across the care continuum resulting in best patient outcomes
Evaluates, selects or designs patient education materials on specific disease site programs
Provides education and outreach programs to patients, Advocate staff and to members of the community
Assist leadership in developing program vision, goals and objectives

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
Premium pay such as shift, on call, and more based on a teammate's job
Incentive pay for select positions
Opportunity for annual increases based on performance

Fulltime

Hospice Clinical Liaison

JourneyCare Hospice is seeking a Hospice Clinical Liaison to join our growing te...

Location

United States , Glenview

Salary:

75000.00 - 92000.00 USD / Year

Arcadia Home Care and Staffing - an Addus family company

Expiration Date

Until further notice

Requirements

Graduate from an accredited registered nursing program
Licensed as a registered nurse in the state of practice
Must possess current CPR, First Aid Certification
1 year experience, preferred
Willingness to travel 50% or more in assigned territory
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

Respond promptly to hospice referrals and perform real-time, bedside clinical assessments
Support the admission process by assisting with initial patient intake, including explaining hospice services and benefits to patients and families in both home and clinical settings
Gather comprehensive data on physical, psychological, social, and spiritual factors that may impact the patient’s and family’s needs and coordinate appropriate interventions with the interdisciplinary team
Conduct clinical assessments and gather information to support physician determination of hospice eligibility
Build and maintain client relationships
Responds to customer needs and concerns in a timely manner
Completes required admission documentation, including consents and CTI (Certification of Terminal Illness) coordination
Facilitate and activate the admission workflow for eligible patients in collaboration with the hospice team
Coordinate and support General Inpatient (GIP) admissions in partnership with the hospice centers
Serve as an on-site clinical presence for immediate admissions or as a resource to field RNs, as needed

What we offer

Great culture and team atmosphere
Comprehensive benefits (medical, dental, vision, life/AD&D, disability) effective on the first of the month following start date
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

New

Complex Inpatient Medical Social Worker

Provides care management/social work services to Complex patients, families, and...

Location

United States

Salary:

33.05 - 49.60 USD / Hour

Advocate Aurora Health

Expiration Date

Until further notice

Requirements

Master’s Degree in Social Work
LSW license issued by the State in which the team member practices (WI & IL Divisions)
Accredited Case Manger SW (ACM-SW) certification issued by the American Case Management Association (ACM) needs to be obtained within 2 years, or Certified Case Manager (CCM) issued by the Commission for Case Manager Certification (CCMC) needs to be obtained within 2 years, or Certified Social Worker in Health Care (C-SWHC) issued by National Association of Social Workers to be obtained within 2 years
3 years of hospital care management experience
Ability to prioritize and organize work
Effective communication skills
Utilization of critical thinking and timely decision making
Ability to navigate the electronic health record
Basic utilization of MS Office products
Knowledge of Medicare A and B guidelines

Job Responsibility

Provides care management/social work services to Complex patients, families, and individuals including perming thorough patient psychosocial assessments, screening, determination of needs evaluation, appropriate interventions and follow up, and discharge planning
Implements targeted interventions and patient-family centered care plans to achieve optimal health outcomes
Collaborates and negotiates effectively with socially complex patients, family and the clinical team while striving to achieve patient and organizational goals regarding care needs, choices, and satisfaction during discharge planning and care transitions
Provide continuity of care and discharge planning services for socially complex patients compliant with regulatory standards
Offers coordinated, relevant options and services based on assessed needs to ensure patient, families, and the healthcare team are informed and prepared to proceed with accountabilities in a timely manner
Participates in the communication processes to facilitate smooth transitions for patients, families, and staff during patient transfers
Provides advanced care management guidance and mentorship to frontline care management team members fostering a culture of excellence and continuous improvement
Lead initiatives aimed at enhancing care quality, patient safety, and overall healthcare delivery efficiency
Creates relationships with community resources to facilitate referrals for Complex patients and is viewed as an expert with area resources
Initiates internal and external referrals to ensure timely progression of care and transitions for socially complex patients

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
Premium pay such as shift, on call, and more based on a teammate's job
Incentive pay for select positions
Opportunity for annual increases based on performance

Fulltime

Rn - Transitional Care Navigator

Arcadia Home Care and Staffing - an Addus family company

Location:
United States , Meridian

Category:
Nursing

Contract Type:
Not provided

Salary:

Job Description:

Job Responsibility:

Requirements:

Additional Information:

Job Posted:
December 20, 2025

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