Transition of Care Coach, CVS Health

CVS Health

Location:
United States

Category:
Nursing

Contract Type:
Employment contract

Salary:

22.40 - 53.53 USD / Hour

Save Job

Apply Position

Job Description:

The Transition of Care Coach is responsible for care coordination of our members who are experiencing a significant change in health status which has resulted in the necessity of an emergency department visit, inpatient, skilled nursing, or rehabilitative stay. Under the direction of a Registered/Licensed RN, the TOC Coach ensures the member experiences a seamless transition to their next care setting and facilitates post-discharge goal attainment.

Job Responsibility:

Care coordination of members experiencing significant change in health status
Complete post-discharge questionnaire
Ensure member has filled/received medications and understands how to take them
Benefit education
Monitor members in low CM level for alerts or changes in condition
Complete post discharge call and required assessments
Complete inpatient confinement calls and monitoring for discharge
Management of warm transfers from concierge and engagement hub
Provides clinical assistance to determine appropriate services and supports
Evaluation of health and social indicators
Identifies and engages barriers to achieving optimal member health
Facilitates overall care coordination with the care team
Coordinates post-discharge meal delivery, assists with securing DME, and helps ensure timely physician follow-up
Understands Payer/Plan benefits, policies, procedures
Complete outreach cadence calls and post-discharge questionnaires within compliance timelines
Utilize weekly and daily reporting to identify utilization
Follow members identified as inpatient in hospitals
Facilitates Interdisciplinary Care Team Meetings

Requirements:

Active license in CT, NY or Compact
1 year of advanced proficiency in Microsoft Word, Excel, and Outlook
Active and unrestricted Licensed Practical Nurse (LPN) in NY or PA
Hospice/palliative care experience

Nice to have:

Ability to multitask, prioritize, and effectively adapt to a fast-paced changing environment
Effective verbal and written communication skills
Bilingual (English/Spanish)
Home Health experience
Associate's Degree and/or Bachelor's Degree

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 and 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 07, 2025

Expiration:
September 19, 2025

Employment Type:

Fulltime

Work Type:

Remote work

View All Jobs In This Company

Job Link Share:

Transition of Care Coach