Transitional Care Management Registered Nurse

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

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.