Transition of Care Associate, Licensed Practical Nurse, Remote

Hispanic Alliance for Career Enhancement; Austin (TX); Remote; USD 60,000 - 80,000; Full time

Job summary

Join a compassionate team dedicated to transforming healthcare for dual eligible populations. As a Transition of Care Coach, you will play a pivotal role in ensuring seamless transitions for members facing significant health changes. This full-time telework position offers an opportunity to make a life-changing impact while collaborating with a multidisciplinary team. You will be responsible for care coordination, discharge planning, and addressing members' health needs with a holistic approach. If you're a detail-oriented LPN with a passion for patient advocacy, this role is perfect for you.

Benefits

Affordable medical plan options

401(k) plan with matching contributions

Employee stock purchase plan

Wellness screenings

Tobacco cessation programs

Weight management programs

Confidential counseling

Financial coaching

Flexible work schedules

Tuition assistance

Qualifications

• 2+ years LPN nursing experience required.
• Active LPN license in the state of residence is mandatory.

Responsibilities

• Coordinate care for members post-discharge to ensure smooth transitions.
• Conduct outreach calls and complete post-discharge questionnaires.

Skills

LPN nursing experience

Communication skills

Microsoft Word

Microsoft Excel

Microsoft Outlook

Bilingual

Education

LPN Certification

Associate's Degree

Bachelor's Degree

Job description

At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues - caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

This is a full-time telework position.

**This position will require 8a-5p in the assigned market time zone.**

Help us elevate our member care to a whole new level! Join our Aetna Team as an industry leader in serving dual eligible populations by utilizing best-in-class operating and clinical models. You can have life-changing impact on our Dual Eligible Special Needs Plan (D-SNP) members, who are enrolled in Medicare and Medicaid and present with a wide range of complex health and social challenges. With compassionate attention and excellent communication, we collaborate with members, providers, and community organizations to address the full continuum of our members' health care and social determinant needs. Join us in this exciting opportunity as we grow and expand D-SNP to change lives in new markets across the country.

The Transition of Care Coach is responsible for care coordination of our members who are experiencing a significant change in health status which has resulted in the necessity of an emergency department visit, inpatient, skilled nursing, or rehabilitative stay. The TOC Coach ensures the member experiences a seamless transition to their next care setting and facilitates post-discharge goal attainment by:

• Complete post-discharge questionnaire, which may be market specific.
• Providing comprehensive discharge planning
• Ensures the member has filled/received their medication(s) and has an understanding on how to take their ordered medications.
• Benefit education
• Provides clinical assistance to determine appropriate services and supports due to member's health needs (including but not limited to: Prior Authorizations, Coordination with PCP and Specialty providers, Condition Management information and education, Medication management, Community Resources and supports)
• Evaluation of health and social indicators
• Identifies and engages barriers to achieving optimal member health.
• Uses discretion to apply strategies to reduce member risk.
• Presents cases at case conferences for multidisciplinary focus to benefit overall member management.
• Facilitates overall care coordination with the care team to ensure member achieves optimal wellness within the confines of the member's condition(s) and abilities to self-manage.
• Coordinates post-discharge meal delivery, assists with securing DME, and helps to ensure timely physician follow-up.
• Understands Payer/Plan benefits, policies, procedures, and can articulate them effectively to providers, members, and other key personnel.
• Updates the Care Plan for any change in condition or behavioral health status.

Our TOC Coaches are frontline advocates for members who cannot advocate for themselves. The TOC team will review prior claims to address potential impact on current case management and eligibility status. Assessments and/or questionnaires are designed to use a holistic approach to identify the need for a referral to clinical resources for assistance in functionality.

RESPONSIBILITIES

Responsible for completing outreach cadence calls and post-discharge questionnaires within required compliance driven timelines.

Utilizes weekly and daily reporting to identify utilization for the purpose of reducing Emergency Department Utilization and 30-day hospital readmissions.

Follows members identified as inpatient in hospitals (whether planned or unplanned admission) and then throughout the subsequent care continuum until member can return to prior level of functioning in the community.

Facilitates Interdisciplinary Care Team Meetings with Social Services, Care Management, PCP and other key players to discuss service needs and support safe transitions.

REQUIRED WORK EXPERIENCE

• 2+ years LPN nursing experience
• Active and unrestricted LPN license in the state of residence
• Proficiency in Microsoft Word, Excel, and Outlook

PREFERRED WORK EXPERIENCE

• 3+ years LPN nursing experience
• Self-motivated, energetic, detail-oriented, highly organized, tech-savvy Licensed Practical Nurses
• Discharge planning experience
• Ability to multitask, prioritize, and effectively adapt to a fast-paced changing environment while providing outstanding care.
• Effective verbal and written communication skills
• Bilingual a plus!

EDUCATION

• Required: H.S. or Equivalent - MUST be an LPN
• Preferred: Associate's Degree, Bachelor's Degree

Anticipated Weekly Hours
40

Time Type
Full time

Pay Range

The typical pay range for this role is:

$22.40 - $48.67

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in our comprehensive and competitive mix of pay and benefits - investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit https://jobs.cvshealth.com/us/en/benefits

We anticipate the application window for this opening will close on: 05/30/2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.