Remote Part-Time Transitional Care RN Navigator

Hugh Chatham Health; Milwaukee (WI); Remote; USD 53,000 - 79,000; Part time

Benefits offered by this job

Paid Time Off

Health benefits

Educational assistance

Job summary

Advocate Aurora Health is seeking a part-time, fully remote Transitional Care RN to lead post‑discharge support for high‑risk patients. You will perform assessments, develop patient‑centered care plans, coordinate with care teams, and educate patients on managing their conditions.

The role emphasizes CMS guidelines compliance, documentation accuracy, and participation in quality improvement initiatives, with a 20‑hour workweek and weekend coverage as needed.

Qualifications

• RN currently licensed and with a BSN or higher.
• Minimum of five years of clinical nursing experience in acute/post-acute/transitional care.
• Minimum of three years with complex patient populations (heart failure, COPD, GI bleed, sepsis, stroke).

Responsibilities

• Perform comprehensive clinical assessments for high‑risk patients at discharge and during the 30‑day transition window.
• Develop and update individualized care plans focusing on clinical needs, meds, and follow‑up.
• Coordinate with inpatient, PCP, specialists, home health and community resources.
• Educate patients and families on disease management, meds, symptoms, and escalation.
• Manage caseload with post‑discharge follow‑ups, visits, and adherence to plan.
• Lead interdisciplinary rounds and case conferences with providers and staff.
• Monitor progress via outreach, telehealth and calls; intervene as needed.
• Ensure CMS Transitional Care Management and Joint Commission compliance with documentation.
• Engage in quality improvement to strengthen workflows and outcomes.

Skills

Clinical leadership

Care coordination

Critical thinking

Motivational interviewing

Telehealth

EHR proficiency

Education

BSN required

MSN preferred

Tools

Electronic Health Records

Telehealth platforms

Job description

Advocate Aurora Health is seeking a part-time, fully remote Transitional Care RN to lead post‑discharge support for high‑risk patients. You will perform assessments, develop patient‑centered care plans, coordinate with care teams, and educate patients on managing their conditions.

The role emphasizes CMS guidelines compliance, documentation accuracy, and participation in quality improvement initiatives, with a 20‑hour workweek and weekend coverage as needed.