Remote Transitional Care Nurse Navigator

Advocate Health; Milwaukee (WI); À distance; USD 85 000 - 120 000; Plein temps

Résumé du poste

Advocate Health is seeking a registered nurse to lead transitional care for high-risk patients during discharge and the 30-day post-discharge period. You will assess needs, coordinate medications, and arrange follow-up care, while educating patients and families on disease management.

The role emphasizes strong care coordination, interdisciplinary collaboration, and adherence to CMS guidelines, with a primarily remote work environment and occasional on-site meetings in Milwaukee.

Qualifications

• BSN required.

Responsabilités

• Conduct comprehensive clinical assessments of high-risk patients at discharge and during the 30-day transition.
• Develop and update individualized care plans addressing clinical needs, medication management, and follow-up.
• Coordinate care and facilitate timely communication among inpatient teams, primary care, specialists, home health, and community resources.
• Serve as primary contact for patients and families, educating on disease management and escalation protocols.
• Manage a caseload of post-discharge patients and ensure follow-up appointments and home visits.
• Lead/interdisciplinary rounds and case conferences with physicians, pharmacists, social workers, and nurses.
• Monitor progress via outreach, telehealth, and calls; intervene as issues arise.
• Ensure CMS Transitional Care Management and Joint Commission compliance through documentation.
• Participate in quality improvement to strengthen workflows and patient outcomes.
• Perform other duties as assigned.

Connaissances

Care coordination

Clinical decision-making

Interdisciplinary collaboration

Motivational interviewing

Communication skills

Telehealth proficiency

Regulatory knowledge

Documentation accuracy

Leadership

Prioritization

Formation

Bachelor of Science in Nursing (BSN)

Registered Nurse (RN) license

Outils

EHR systems

Telehealth platforms

Care coordination software

Description du poste

Advocate Health is seeking a registered nurse to lead transitional care for high-risk patients during discharge and the 30-day post-discharge period. You will assess needs, coordinate medications, and arrange follow-up care, while educating patients and families on disease management.

The role emphasizes strong care coordination, interdisciplinary collaboration, and adherence to CMS guidelines, with a primarily remote work environment and occasional on-site meetings in Milwaukee.