Remote Transitional Care Nurse Navigator

Aurora Health Care; Milwaukee (WI); Remote; USD 75,000 - 95,000; Full time

Job summary

Aurora Health Care in Milwaukee, WI seeks an experienced Registered Nurse for a Transitional Care Manager role, focused on high-risk patients during discharge and the 30-day post-discharge period.

You will assess needs, develop care plans, coordinate with inpatient and community providers, educate patients, and monitor progress via visits, telehealth, and outreach, while ensuring CMS guidelines and quality goals are met.

Qualifications

• BSN required and active RN license.
• Min 5 years clinical nursing in acute or discharge planning.
• Min 3 years care for complex populations (HF, COPD, sepsis, stroke).
• Strong care coordination, communication, and teaching skills.
• Experience with telehealth and EHRs.

Responsibilities

• Conduct comprehensive clinical assessments of high-risk patients at discharge and during the 30-day transition.
• Develop and update individualized, patient-centered care plans addressing clinical needs, meds, and follow-up.
• Coordinate care among inpatient, PCP, specialists, home health, and community resources.
• Educate patients and families on disease management, meds, monitoring, and escalation protocols.
• Manage a caseload of post-discharge patients and ensure follow-up appointments and home visits.
• Lead and participate in interdisciplinary rounds and case conferences.
• Monitor progress via outreach visits, telehealth, and phone contacts; intervene as needed.
• Ensure CMS TCM and Joint Commission standards through accurate documentation.
• Participate in quality improvement to strengthen transitional care workflows and outcomes.
• Perform other duties as assigned.

Skills

Care coordination

Clinical decision-making

Motivational interviewing

Telehealth

Patient education

Documentation

Education

Bachelor of Science in Nursing (BSN)

Tools

Electronic Health Records (EHR)

Job description

Aurora Health Care in Milwaukee, WI seeks an experienced Registered Nurse for a Transitional Care Manager role, focused on high-risk patients during discharge and the 30-day post-discharge period.

You will assess needs, develop care plans, coordinate with inpatient and community providers, educate patients, and monitor progress via visits, telehealth, and outreach, while ensuring CMS guidelines and quality goals are met.