Transitional Care Management Registered Nurse

Aurora Health Care; Milwaukee (WI); Remote; USD 75,000 - 95,000; Full time

Job summary

Aurora Health Care in Milwaukee, WI seeks an experienced Registered Nurse for a Transitional Care Manager role, focused on high-risk patients during discharge and the 30-day post-discharge period.

You will assess needs, develop care plans, coordinate with inpatient and community providers, educate patients, and monitor progress via visits, telehealth, and outreach, while ensuring CMS guidelines and quality goals are met.

Qualifications

• BSN required and active RN license.
• Min 5 years clinical nursing in acute or discharge planning.
• Min 3 years care for complex populations (HF, COPD, sepsis, stroke).
• Strong care coordination, communication, and teaching skills.
• Experience with telehealth and EHRs.

Responsibilities

• Conduct comprehensive clinical assessments of high-risk patients at discharge and during the 30-day transition.
• Develop and update individualized, patient-centered care plans addressing 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 protocols.
• Manage a caseload of post-discharge patients and ensure follow-up appointments and home visits.
• Lead and participate in interdisciplinary rounds and case conferences.
• Monitor progress via outreach visits, telehealth, and phone contacts; intervene as needed.
• Ensure CMS TCM and Joint Commission standards through accurate documentation.
• Participate in quality improvement to strengthen transitional care workflows and outcomes.
• Perform other duties as assigned.

Skills

Care coordination

Clinical decision-making

Motivational interviewing

Telehealth

Patient education

Documentation

Education

Bachelor of Science in Nursing (BSN)

Tools

Electronic Health Records (EHR)

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.