Registered Nurse (RN) - Transitions of Care

Job Title: RN (Transitions of Care) Duration: 3 Months Location: Remote Shift: Monday - Friday (8 AM - 5 PM CST) Job Summary: Transitions: Care transition support, follow-up coordination, and avoidable readmission prevention for discharged inpatient, observation and emergency department patients Quality: Medicare Advantage Stars, HEDIS and quality performance across value-based population Population Health: Deliver culturally appropriate chronic disease education to activate patients are chronic disease self-management, particularly in Diabetes and Hypertension Duties and Responsibilities: Analyze clinical data and trends from platforms such as Athena EMR and Datahub to identify gaps in care related to HEDIS measures and Transitions of Care and post-hospitalization needs, prioritizing high-impact opportunities. Proactively identify recently discharged inpatient, observation and emergency department patients and coordinate timely post-discharge follow-up in alignment with TOC and Transitional Care Management (TCM) requirements, with the aim of addressing root causes of utilization and supporting patients to prevent avoidable readmissions or return visits. Conduct targeted patient and provider outreach via phone and telehealth visits to close care opportunities, provide tailored education on preventive care, chronic disease management, and medication management. Conduct post-discharge outreach to assess understanding of discharge instructions, bottles-out medication reconciliation, symptom monitoring, and follow-up appointment adherence. Identify and escalate barriers, collaborating with providers and care team to prevent readmissions and avoidable ED utilization. Collaborate effectively with interdisciplinary teams—including providers, care assistants, center administrators, medical assistants, pharmacy, and quality improvement staff—to implement evidence-based interventions and optimize workflows. Required Qualifications: · Bachelor’s degree in nursing · Active, unrestricted RN license in VA or NC. · Minimum of 3 years.