Transitional Care Management Registered Nurse

Advocate Aurora Health; Milwaukee (WI); Remote; USD 85,000 - 120,000; Full time

Job summary

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.

Responsibilities

• 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.

Skills

Care coordination

Clinical decision-making

Interdisciplinary collaboration

Motivational interviewing

Communication skills

Telehealth proficiency

Regulatory knowledge

Documentation accuracy

Leadership

Prioritization

Education

Bachelor of Science in Nursing (BSN)

Registered Nurse (RN) license

Tools

EHR systems

Telehealth platforms

Care coordination software

Job description

Major Responsibilities

• Conduct comprehensive clinical assessments of high‑risk patients at discharge and throughout the 30‑day transitional care period, identifying medical, psychosocial, and environmental risk factors.
• Develop, implement, and continuously update individualized, patient‑centered care plans addressing clinical needs, medication management, and follow‑up care.
• Coordinate care and facilitate timely communication among inpatient providers, primary care, specialists, home health agencies, and community resources.
• Serve as the primary point of contact for patients and families, providing education on disease management, medications, symptom monitoring, and escalation protocols.
• Manage a caseload of post‑discharge patients and ensure completion of follow‑up appointments, home visits, and adherence to prescribed treatments.
• Lead and participate in interdisciplinary rounds and case conferences, collaborating with physicians, pharmacists, social workers, behavioral health providers, and nursing staff.
• Monitor patient progress through outreach visits, telehealth, and phone contacts, intervening promptly when clinical or psychosocial issues arise.
• Ensure compliance with CMS Transitional Care Management guidelines, Joint Commission standards, and organizational policies through accurate and timely documentation.
• Participate in quality improvement initiatives and identify opportunities to strengthen transitional care workflows and patient outcomes.
• Perform other duties and responsibilities as assigned.

Education

• Bachelor of Science in Nursing (BSN) required.

Certification / Registration / License

• Active, unrestricted Registered Nurse (RN) license.

Work Experience

• Minimum of five years of clinical nursing experience in acute care, discharge planning, post‑acute care, or transitional care.
• Minimum of three years of experience providing care and patient education to complex populations, including heart failure, COPD, GI bleed, sepsis, or stroke.

Knowledge / Skills / Abilities

• Advanced clinical expertise in complex patient management and transitional care.
• Strong care coordination, critical thinking, and clinical decision‑making skills.
• Demonstrated leadership in interdisciplinary collaboration and patient advocacy.
• Strong communication skills, including use of motivational interviewing techniques.
• Proficiency with electronic health records, care coordination tools, and telehealth platforms.
• Knowledge of regulatory requirements and reimbursement criteria related to transitional care.
• Strong organizational, analytical, and prioritization skills.
• Commitment to ethical practice, patient‑centered care, and continuous professional development.

Physical Requirements and Working Conditions

• Primarily remote work environment with occasional on‑site meetings.
• Standard schedule is Monday through Friday, 8:00 a.m. – 4:30 p.m., with potential evening or weekend coverage as needed to support patient transitions and caseload requirements.

Preferred Job Requirements

Education

• Master of Science in Nursing or related field preferred.

Certification / Registration / License

• Preferred certifications include Medical‑Surgical RN (MEDSURG‑BC), Cardiac‑Vascular Nursing (CV‑BC), or Nursing Case Management (CMGT‑BC).

Experience

• Additional experience in transitional care or case management preferred.

Knowledge / Skills / Abilities

• Not required beyond minimum qualifications.

All responsibilities and requirements are subject to possible modification to reasonably accommodate individuals with disabilities.
This job description does not state or imply that these are the only duties to be performed. Employees may be required to perform other job‑related duties as requested.