Transitional Care Manager RN

CVS Health; Harrisburg (Dauphin County); Remote; USD 60,000 - 100,000; Full time

Job summary

An innovative health solutions company is seeking a Transitional Care Manager RN to facilitate patient transitions and enhance care continuity. This role is pivotal in advocating for patients, ensuring they receive the necessary resources, and improving workflow efficiencies. The ideal candidate will possess a strong nursing background, exceptional communication skills, and a passion for delivering high-quality care. Join a dynamic team dedicated to transforming healthcare and making a meaningful impact in the lives of patients, especially those in underserved communities. This position offers the opportunity to work in a supportive environment focused on personal and professional growth.

Benefits

401(k) Matching

Health Insurance

Dental Insurance

Vision Insurance

Flexible Schedules

Paid Time Off

Wellness Programs

Family Leave

Qualifications

• 2+ years’ experience in transitional nursing or emergency room nursing.
• Active RN license and willingness to obtain cross-state licensure.

Responsibilities

• Manage patient transitions in various care settings.
• Coordinate with internal teams and external stakeholders for seamless care.

Skills

Transitional Nursing

Emergency Room Nursing

Discharge Planning

Utilization Management

Communication Skills

Problem-Solving Skills

Customer Service Skills

Spanish Language

Education

Active RN License

Certified Case Manager (CCM)

Tools

Microsoft Office Suite

Job description

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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 more connected, more convenient, and more compassionate. And we do it all with heart, each and every day.

Company: Oak Street Health

Title: Transitional Care Manager, RN (CVS Healthspire)

Location: Remote

Oak Street Health is a rapidly growing, innovative company of community-based healthcare centers delivering higher quality health and wellness care that improves outcomes, manages medical costs, and provides an unmatched experience for adults on Medicare in underserved communities. By providing holistic, comprehensive, and integrated care in our patients’ communities, we help keep them healthy and reinvest cost savings into further care for these communities and others. Since 2013, Oak Street Health has expanded its approach nationwide, attracting team members passionate about our mission to rebuild healthcare.

Role Description

Oak Street Health adopts a team-based approach to patient care. The Transitional Care Manager, RN (TCM-RN) supports patients cared for by Oak Street Health’s Managed Service Organization, CVS Healthspire. The TCM-RN is a key member of the clinical team, facilitating interdisciplinary collaboration and care continuity across settings, empowering patients and caregivers to actively participate in post-ED/Observation and post-hospitalization care plans. The role involves providing information, addressing problems, and building relationships with providers across various care sites.

Core Responsibilities

Transitions Management

• Manage patient transitions in various care settings, either face-to-face or telephonically within a defined geographical area.
• Advocate for patients to ensure access to resources and resolve barriers to care.
• Identify opportunities for workflow improvements, partnerships, and higher quality care.
• Maintain accurate records of patient status during care transitions using Oak Street’s inpatient platform.
• Ensure compliance with CMS, state, and NCQA criteria related to Transitions of Care.

Transitions Management Responsibilities May Also Include

• Post-ED/Observation Stays: Evaluate patient status, triage follow-up care, review medications, schedule appointments.
• Hospital Inpatient Stays: Facilitate discharge, coordinate follow-up, review medical records, inform patient/family of care plan and discharge instructions.
• Post-Discharge Care: Conduct assessments, reconcile medications, address post-discharge needs collaboratively.

Collaboration and Communication

Coordinate with internal teams (social work, PCP, behavioral health) and external stakeholders to ensure seamless patient care and program development. Participate in meetings and contribute to quality assurance activities.

Qualifications

• Active RN license in good standing within the state of practice; willingness to obtain cross-state licensure.
• Certified Case Manager (CCM) or similar certification required or within 12 months of hire.
• 2+ years’ experience in transitional nursing, emergency room nursing, discharge planning, or home health.
• Experience in utilization management preferred.
• Knowledge of Medicare/Medicaid, NCQA regulations, and care transition criteria.
• Exceptional communication, problem-solving, and customer service skills.
• Additional language (Spanish) preferred but not required.
• Valid driver’s license and ability to travel daily.
• Proficiency in Microsoft Office Suite.

Additional Information

Embody “Oaky” values: positive energy, good intentions, excellent patient experience, clinical excellence, ownership, and determination.

Why Oak Street Health? We focus on personalized primary care for older adults on Medicare, promoting health and independence in community settings. With over 150 locations and an ambitious growth plan, we seek team members aligned with our mission and values.

Benefits

• Impactful career with measurable health outcomes.
• Competitive pay, paid time off, 401(k) matching, health/dental/vision insurance.
• Wellness programs, flexible schedules, family leave, and other benefits.

Application deadline: 11/05/2025. We are an equal opportunity employer committed to diversity and inclusion. Learn more at our website.