Transition of Care Associate - Licensed Practical Nurse, CVS Health

CVS Health

Location:
United States, Work At Home

Category:
Nursing

Contract Type:
Employment contract

Salary:

21.10 - 43.78 USD / Hour

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Job Description:

Transition of Care Coach responsible for care coordination of members experiencing significant changes in health status resulting from emergency department visits, inpatient, skilled nursing, or rehabilitative stays. Works under direction of Registered/Licensed RN to ensure seamless transitions between care settings and facilitate post-discharge goal attainment for dual eligible populations.

Job Responsibility:

Complete post-discharge questionnaire
Ensure member has filled/received medications and understands how to take them
Provide benefit education
Monitor members in low CM level for alerts or changes in condition
Complete post discharge call and required assessments (RAP)
Complete medication reconciliation (if within scope of practice)
Complete fall assessment if fall risk identified
Complete inpatient confinement calls and monitoring for discharge
Manage warm transfers from concierge and engagement hub
Provide clinical assistance to determine appropriate services and supports
Evaluate health and social indicators
Identify and engage barriers to achieving optimal member health
Apply strategies to reduce member risk
Facilitate overall care coordination with the care team
Coordinate post-discharge meal delivery
Assist with securing DME
Ensure timely physician follow-up
Understand Payer/Plan benefits and articulate them effectively
Complete outreach cadence calls within required compliance timelines
Facilitate Interdisciplinary Care Team Meetings
Follow members identified as inpatient throughout care continuum
Utilize weekly and daily reporting to identify utilization

Requirements:

Active and unrestricted Compact Licensed Practical Nurse (LPN) License in state of residence
3+ years of Licensed Practical Nurse (LPN) nursing experience
2+ years of discharge planning experience and/or hospice experience understanding the complexities of end of life (EOL) care
2+ years of experience with Microsoft Word, Excel, and Outlook
3+ years clinical practical experience with preference in the following areas: diabetes, Congestive Heart Failure (CHF), Chronic Kidney Disease (CKD), post-acute care, hospice, palliative care, cardiac, home health with Medicare members
High School Diploma/GED or equivalent experience

Nice to have:

4+ years of Licensed Practical Nurse (LPN) nursing experience
Living in the Southeast Region (States Included but Not Limited To - FL, GA, AL, MS, NC, SC, TN)
Associate's or Bachelor of Science in Nursing

What we offer:

Affordable medical plan options
401(k) plan with matching company contributions
Employee stock purchase plan
No-cost wellness screenings
Tobacco cessation and weight management programs
Confidential counseling
Financial coaching
Paid time off
Flexible work schedules
Family leave
Dependent care resources
Colleague assistance programs
Tuition assistance
Retiree medical access

Additional Information:

Job Posted:
September 23, 2025

Expiration:
September 30, 2025

Employment Type:

Fulltime

Work Type:

Remote work

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Transition of Care Associate - Licensed Practical Nurse