Remote Transitional Care RN — Lead Discharge & Care Coordination

Aurora Health Care; Milwaukee (WI); Remote; USD 85,000 - 110,000; Full time

Job summary

Aurora Health Care is seeking a Remote Transitional Care Nurse Manager to drive comprehensive post-discharge care for high-risk patients. You will develop patient-centered plans, coordinate across hospitals, PCPs, specialists, and home health, and educate families on disease management and follow-up.

The role emphasizes strong communication, advanced nursing expertise in transitional care, and a commitment to ethical, patient-centered practice.

Qualifications

• RN license active and unrestricted.
• Minimum five years clinical nursing experience in acute, discharge, post-acute, or transitional care.
• Minimum three years providing care and education to complex populations (e.g., heart failure, COPD, GI bleed, sepsis, stroke).
• Strong communication and motivational interviewing skills.
• Proficiency with electronic health records and telehealth platforms.
• Knowledge of CMS Transitional Care Management guidelines and Joint Commission standards.

Responsibilities

• Assess high-risk patients at discharge and during the 30-day transition period.
• Develop and update individualized, patient-centered care plans for 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.
• Manage caseload and ensure follow-up appointments, home visits, and adherence.
• Lead interdisciplinary rounds and case conferences with the care team.
• Monitor progress via outreach, telehealth, and calls; intervene as needed.
• Ensure CMS TCM and Joint Commission compliance through timely documentation.
• Contribute to quality improvement and better transition workflows.

Skills

Care coordination

Clinical decision-making

Leadership

Communication skills

EHR proficiency

Regulatory knowledge

Analytical skills

Organizational skills

Ethical practice

Education

BSN required

MSN preferred

Tools

Telehealth platforms

Care coordination tools

Job description

Aurora Health Care is seeking a Remote Transitional Care Nurse Manager to drive comprehensive post-discharge care for high-risk patients. You will develop patient-centered plans, coordinate across hospitals, PCPs, specialists, and home health, and educate families on disease management and follow-up.

The role emphasizes strong communication, advanced nursing expertise in transitional care, and a commitment to ethical, patient-centered practice.