Transition of Care Nurse - RN

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.
 
Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

Fully remote.

Schedule: Monday-Friday 8:00am- 5:00pm EST.

Position Summary

The Transition of Care RN is responsible for care coordination of our members who are experiencing a significant change in health status which has resulted in the necessity of an emergency department visit, inpatient, skilled nursing, or rehabilitative stay. The Transition of Care RN ensures the member experiences a seamless transition to their next care setting and facilitates post-discharge goal attainment by:

• Complete post-discharge questionnaire, which may be market specific.
• Ensures the member has filled/received their medication(s) and has an understanding on how to take their ordered medications.
• Benefit education
• Monitor members in low CM level for alerts or changes in condition to be transitioned back to RN.
• Complete post discharge call and required assessments (RAP), medication reconciliation (if within scope of practice), fall assessment if fall risk identified.
• Complete inpatient confinement calls and monitoring for discharge.
• Management of warm transfers form concierge and engagement hub
• Provides clinical assistance to determine appropriate services and supports due to member’s health needs (including but not limited to: Coordination with PCP and Specialty providers, Condition Management information and education, Medication management, Community Resources and supports)
• Evaluation of health and social indicators
• Identifies and engages barriers to achieving optimal member health.
• Uses discretion to apply strategies to reduce member risk.
• Facilitates overall care coordination with the care team to ensure member achieves optimal wellness within the confines of the member’s condition(s) and abilities to self-manage.
• Coordinates post-discharge meal delivery, assists with securing DME, and helps to ensure timely physician follow-up.
• Understands Payer/Plan benefits, policies, procedures, and can articulate them effectively to providers, members, and other key personnel.

Our TOC RNs are frontline advocates for members who cannot advocate for themselves. The TOC team will review prior claims to address potential impact on current case management and eligibility status. Focus assessments and/or questionnaires are designed to use a holistic approach to identify the need for a referral to clinical resources for assistance in functionality.

Required Qualifications

• Must have active and unrestricted RN licensure in the state of residence with a requirement to obtain VA RN licensure within 1 month of hire.
• Must be able to work 8:00a - 5:00p EST
• 3+ years clinical practice experience as a Registered Nurse

Preferred Qualifications

• 2+ years Care Management, discharge planning and/or home health care coordination experience preferred
• Prior transition of care experience
• Confidence working at home/independent thinker, using tools to collaborate and connect with teams virtually
• Excellent analytical and problem-solving skills
• Effective communications, organizational, and interpersonal skills.
• Ability to work independently
• Effective computer skills including navigating multiple systems and keyboarding
• Demonstrates proficiency with standard corporate software applications, including MS Word, Excel, Outlook, and PowerPoint, as well as some special proprietary applications

Education

• Associate's degree minimum
• BSN preferred

Pay Range

The typical pay range for this role is:

$66,575.08 - $142,576.72

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.  The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.  This position is eligible for a CVS Heal