Transitional Care Navigator Job at Arcadia Home Care and Staffing

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

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

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

Licensed Nurse Care Coordinator Senior - Population Health

An LVN/ LPN plays a crucial role in managing patient care and ensuring continuit...

Location

United States , Irving

Salary:

Not provided

CHRISTUS Health

Expiration Date

Until further notice

Requirements

High School Diploma required
Minimum of 3 years of clinical or home health experience required
5 years supporting value-based care programs, accountable care organizations, or HEDIS
Knowledge of government programs (CMS), accountable care organizations (ACOs), HEDIS, and experience with payor cost sharing initiatives preferred
Knowledge of physician office practice operations and 3 years of experience in a physician practice is preferred
Proficiency in keyboarding and EHR systems, primarily Epic
LVN/ LPN in the state of employment and/or compact licensure required

Job Responsibility

Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders
Mentor, train and support the team of care coordinators, ensuring high-quality care and adherence to best practices
Assist with work assignments and development of new work processes as needed
Coordinate and assist with associate onboarding
Create education material for training
Monitor and ensure compliance with all regulatory requirements, organizational policies, standing delegated orders and protocols
Identify quality gaps and risk adjustment gaps
Participate in Quality Improvement Programs as indicated
Attend learning sessions and share information learned with team members
Assist in the development of tools, education, and workflow processes to assist the network in meeting CMS, ACO, documentation, and payor quality initiatives

Fulltime

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

Alternate Level of Care Community Nurse

The Alternate Level of Care (ALC) Community Nurse will ensure that hospital goal...

Location

Canada

Salary:

44.19 - 57.68 CAD / Hour

Riverside Health Care

Expiration Date

Until further notice

Requirements

University degree in Health or Social Sciences field
or College Diploma with five (5) years’ work experience in the health and/or social work field
Clinical experience is an asset
Experience in rural nursing, working with indigenous people is an asset
Knowledge of community programming, long term care, convalescent care and other health and services agencies – locally and regionally
Work experience in primary care is an asset
Knowledge of Informed Decision Making, Patient Capacity, Patient Rights and Consent for Treatment
Possess effective oral and written communication and organizational skills
Strong interpersonal and team building skills
Demonstrated initiative and experience working independently and with minimal supervision

Job Responsibility

Work to create/broaden partnerships with allied health and social wellness partners throughout the region to transition ALC patients more effectively from hospital to community programming, home, and long-term care (LTC)
Proactively engage with local and regional allied health and social wellness partners to develop pathways that will avoid ALC designations by addressing patient/client needs and barriers pre-emptively
Become involved in creating strategies that lead to early identification of potential ALC patients in the community and hospital setting
Examine causes of delayed transitions for ALC patients and, as part of an interdisciplinary team, design approaches to counter the delays
Collaborate with health partners to collect, analyse, and critically evaluate data as it relates to ALC patient trends for the Rainy River District
Facilitate transitions of care
Be physically present for warm hand-offs to ease the transition for the ALC patient moving from hospital to home care (nursing/PSS)
Be physically present for ALC patient discharges from hospital to home for those with little to no caregiver support
Complete regular, on-site check-ins for assessment of instrumental activities of daily living for this patient population
Facilitating transitions from Hospital to long-term care

Fulltime

New

Full Time Alternate Level of Care Community Nurse

The Alternate Level of Care (ALC) Community Nurse will ensure that hospital goal...

Location

Canada

Salary:

44.19 - 57.68 CAD / Hour

Riverside Health Care

Expiration Date

Until further notice

Requirements

University degree in Health or Social Sciences field
or College Diploma with five (5) years’ work experience in the health and /or social work field
Clinical experience
Experience in rural nursing, working with indigenous people
Knowledge of community programming, long term care, convalescent care and other health and services agencies – locally and regionally
Work experience in primary care
Knowledge of Informed Decision Making, Patient Capacity, Patient Rights an Consent for Treatment
Possess effective oral and written communication and organizational skills
Strong interpersonal and team building skills
Demonstrated initiative and experience working independently and with minimal supervision

Job Responsibility

Work to create/broaden partnerships with allied health and social wellness partners throughout the region to transition ALC patients more effectively from hospital to community programming, home, and long-term care (LTC)
Proactively engage with local and regional allied health and social wellness partners to develop pathways that will avoid ALC designations by addressing patient/client needs and barriers pre-emptively
Become involved in creating strategies that lead to early identification of potential ALC patients in the community and hospital setting
Examine causes of delayed transitions for ALC patients and, as part of an interdisciplinary team, design approaches to counter the delays
Collaborate with health partners to collect, analyse, and critically evaluate data as it relates to ALC patient trends for the Rainy River District
Facilitate transitions of care
Be physically present for warm hand-offs to ease the transition for the ALC patient moving from hospital to home care (nursing/PSS)
Be physically present for ALC patient discharges from hospital to home for those with little to no caregiver support
Complete regular, on-site check-ins for assessment of instrumental activities of daily living for this patient population
in facilitating transitions from Hospital to long-term care

Fulltime

New

Registered Nurse - Case Manager

We’re building a world of health around every individual — shaping a more connec...

Location

United States , Columbus

Salary:

60522.00 - 129615.00 USD / Year

CVS Health

Expiration Date

June 30, 2026

Requirements

Current RN license in assigned state is required
Bachelor degree in nursing preferred
Minimum of 6-8 years nursing experience
Certified Case Manager (CCM) required, or willingness to obtain within 12 months of hire, unless candidate has 2-3 years of relevant care/case management experience
2+ years experience in transitional nursing, emergency room nursing, care coordination, discharge planning, or home health is strongly preferred
Demonstrated skill in motivational interviewing, patient activation, time management, and navigating community and social resources
A flexible and positive attitude
Comfort with ambiguity and change
High emotional intelligence as evidenced by ability to evaluate/perceive a situation from multiple lenses and understand various perspectives in coming to problem resolution
Access to reliable transportation and ability to travel throughout the communities OSH serves

Job Responsibility

Manages an assigned caseload of complex patients in a value-based care environment, with a focus on driving reduced admissions, readmissions, and medical utilization
Accountable for panel metric performance in admission prevention, readmission prevention, and transitions of care metrics
Owns overall care coordination for assigned patients, functioning as the primary point of contact and ensuring alignment, accountability, and follow-through across the care team
Manage transitions of care episodes for patients on their panel, including timely completion of structured clinical assessments to identify post-discharge needs, medication reconciliation on behalf of the PCP, and addressal of identified needs directly or via collaboration with other team members
Collaborates patient’s PCP, family/caregiver, Social Worker, Behavioral Health Specialists, and other care team members, as needed to evaluate the individual's needs, goals, and plan of action and ensure care plan progression
Ensure timely documentation of key clinical assessments after admissions, while balancing in-center care team planning meetings
Lead in-person interdisciplinary care planning meetings to ensure effective care coordination and management between providers visits
Perform timely nursing assessments and provide patient education for chronic condition management and transitions of care
Educate patients and families, empowering them in their care, and advocating for their needs
Document visits in electronic health record according to internal standards

What we offer

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 our 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

Transitional Care Navigator

Arcadia Home Care and Staffing - an Addus family company

Location:
United States , Naperville

Category:
Nursing

Contract Type:
Not provided

Salary:

Job Description:

Job Responsibility:

Requirements:

Additional Information:

Job Posted:
December 20, 2025

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