[Hiring] Transition of Care - Registered Nurse @CVS Health

Role Description

Help us elevate our member care to a whole new level! Join our Aetna team as an industry leader in serving dual eligible populations by utilizing best-in-class operating and clinical models. You can have life-changing impact on our Fully Integrated Dual Eligible Plan (FIDE) members, who are enrolled in Medicare and Medicaid and present with a wide range of complex health and social challenges. With compassionate attention and excellent communication, we collaborate with members, providers, and community organizations to address the full continuum of our members' health care and social determinant needs.

The Transition of Care CM plays a critical role in ensuring that our high-risk, medically complex, and vulnerable members—those enrolled in HIDE/FIDE SNP and other Medicaid waiver programs—experience safe, effective, and seamless transitions across care settings. The TOC CM ensures the member experiences a seamless transition to their next care setting. This includes members undergoing significant changes in health status that result in emergency department visits, inpatient admissions, or stays in skilled nursing or rehabilitative facilities. This position provides comprehensive care coordination, assists with the development and implementation of care plans, facilitates communication with interdisciplinary teams, and supports members and families to reduce readmissions, promote health equity and improve health outcomes.

Through person-centered planning and timely interventions, the TOC CM ensures that all necessary care, supports, and services are in place at discharge to maintain continuity of care and support optimal recovery.

Qualifications

• Candidate must have an active and unrestricted Registered Nurse (RN) License in Illinois or willing to obtain
• 3+ years of clinical practice experience
• 1+ year(s) of experience in care coordination or working with high-risk populations
• Proficient in Microsoft Office Suite, including Word, Excel, Outlook, OneNote, and Teams
• Confidence working at home / independent thinker, using tools to collaborate and connect with teams virtually
• Access to a private, dedicated space to conduct work effectively

Requirements

• Complete a market specific post discharge assessment to identify member’s needs, including Health Related Social Needs and Social Determinants of Health (SDoH)
• Providing comprehensive discharge planning, including facilitating transitions of care between institutional and community settings
• Ensuring the member has filled/received their medication(s) and has an understanding on how to take their ordered medications
• Providing clinical assistance to determine appropriate services and supports due to member’s health needs
• Identifying and engaging barriers to achieving optimal member health
• Utilizing discretion to apply strategies to reduce member risk
• Lead and coordinate the Interdisciplinary Care Team (ICT) to develop and implement Individualized Care Plans (ICPs)
• Facilitating overall care coordination with the care team to ensure member achieves optimal wellness
• Coordinating post-discharge meal delivery, assists with securing DME, and helps to ensure timely physician follow-up
• Provide education to members and caregivers on care plans, medications, and available community resources
• Understanding Payer/Plan benefits, policies, procedures, and articulating them effectively
• Updating the Care Plan for any change in condition or behavioral health status
• Responsible for completing outreach cadence calls and post-discharge questionnaires within required compliance driven timelines
• Schedule follow-up appointments and ensure medication reconciliation is completed
• Identify and address barriers to care such as transportation, housing, or access to medications
• Utilizes weekly and daily reporting to identify utilization for the purpose of reducing Emergency Department Utilization and 30-day hospital readmissions
• Follows members identified as inpatient in hospitals and throughout the subsequent care continuum
• Facilitates Interdisciplinary Care Team Meetings with Social Services, Care Management, PCP and other key players
• Ensure compliance with state and federal regulations, including NCQA standards

Benefits

• Comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families
• Medical, dental, and vision coverage
• Paid time off
• Retirement savings options
• Wellness programs and other resources, based on eligibility

Education

• Associate’s Degree in Nursing (REQUIRED)
• Bachelor’s Degree in Nursing (PREFERRED)

License

• Active and unrestricted Registered Nurse (RN) License in Illinois or willing to obtain

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is: $66,575.00 - $142,576.00. This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.

This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.