Remote RN: Transitional Care & Care Coordination

Advocate Health; United States; Remote; USD 54,729,000 - 82,094,000; Part time

Benefits offered by this job

Paid Time Off

Health and welfare benefits

Job summary

Advocate Health is seeking a Part-time Transitions of Care RN (remote) to support high‑risk patients across the United States. You will conduct comprehensive assessments at discharge and during the 30‑day transition, and develop individualized care plans.

You will coordinate care among inpatient teams, primary care, specialists, and home health, educate patients on disease management, and monitor progress via telehealth.

Qualifications

• BSN required.
• Active, unrestricted RN license.
• Minimum five years of clinical nursing in appropriate settings.
• Minimum three years of experience with complex populations.

Responsibilities

• Conduct comprehensive assessments of high-risk patients at discharge and during 30-day transition.
• Develop and update individualized care plans including medication management.
• Coordinate care among inpatient, primary care, specialists, and home health agencies.
• Educate patients and families on disease management and follow-up.
• Manage caseload, schedule follow-ups, and ensure adherence to treatments.
• Lead interdisciplinary rounds and collaborate with care teams.
• Monitor progress via outreach, telehealth, and phone contacts; intervene as needed.
• Ensure CMS and accreditation compliance through timely documentation.
• Participate in quality improvement to strengthen workflows and outcomes.
• Perform other duties as assigned.

Skills

Care coordination

Clinical nursing

Patient education

Telehealth

Education

BSN

Tools

EHR systems

Care coordination tools

Telehealth platforms

Job description

Advocate Health is seeking a Part-time Transitions of Care RN (remote) to support high‑risk patients across the United States. You will conduct comprehensive assessments at discharge and during the 30‑day transition, and develop individualized care plans.

You will coordinate care among inpatient teams, primary care, specialists, and home health, educate patients on disease management, and monitor progress via telehealth.