Remote Transitional Care RN Navigator

Advocate Health; Milwaukee (WI); Remote; USD 90,000 - 110,000; Full time

Job summary

Advocate Health is seeking an experienced Registered Nurse for a remote-based Transitional Care role focused on high-risk patients undergoing discharge and 30-day transitions. The role emphasizes comprehensive assessments, patient education, and robust care coordination to improve outcomes.

Ideal candidates hold a BSN, an active RN license, and at least five years in acute or transitional care with exposure to complex populations. Some on-site meetings may be required.

Qualifications

• Bachelor of Science in Nursing (BSN) required.
• Active, unrestricted RN license.
• Minimum five years of clinical nursing experience in acute or transitional care.
• Three years of experience with complex populations (heart failure, COPD, sepsis, stroke).
• Knowledge of CMS Transitional Care Management guidelines and regulatory requirements.

Responsibilities

• Conduct comprehensive clinical assessments during discharge and 30-day transition.
• Develop and update patient-centered care plans addressing meds and follow-up.
• Coordinate care among inpatient, primary care, specialists, and home health.
• Educate patients and families on disease management and escalation protocols.
• Manage a caseload and ensure follow-up visits and adherence.
• Lead interdisciplinary rounds and participate in case conferences.
• Monitor progress via outreach visits, telehealth, and calls; intervene as needed.
• Ensure documentation complies with CMS and Joint Commission standards.
• Participate in quality improvement to strengthen workflows and outcomes.
• Perform other duties as assigned.

Skills

Clinical nursing expertise

Care coordination

Communication skills

Telehealth proficiency

Education

BSN

MSN (preferred)

Tools

Electronic Health Records

Care coordination tools

Telehealth platforms

Job description

Advocate Health is seeking an experienced Registered Nurse for a remote-based Transitional Care role focused on high-risk patients undergoing discharge and 30-day transitions. The role emphasizes comprehensive assessments, patient education, and robust care coordination to improve outcomes.

Ideal candidates hold a BSN, an active RN license, and at least five years in acute or transitional care with exposure to complex populations. Some on-site meetings may be required.