Transitional Care Management Nurse

Advocate Aurora Health

. Conduct comprehensive clinical assessments of high-risk patients at discharge and throughout the 30-day transitional care period .

Posted 9/24/2026part-timeMint Hill • North Carolina • United StatesMid-LevelSenior💰 $38 - $57 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates advanced clinical expertise in managing complex patient populations and transitional care, with a strong focus on care coordination, patient education, and adherence to regulatory standards.

Highest-signal resume keywords

Bachelor Of Science In Nursing (BSN)Registered Nurse (RN) LicenseClinical Nursing ExperienceCare CoordinationElectronic Health Records Proficiency

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical AssessmentPatient-Centered Care PlansTransitional Care ManagementDisease Management EducationSymptom MonitoringQuality Improvement InitiativesRegulatory ComplianceCritical ThinkingClinical Decision-MakingMotivational Interviewing Techniques

Soft Skills

Strong Communication SkillsLeadership In Interdisciplinary CollaborationPatient AdvocacyOrganizational SkillsAnalytical Skills

Tools & Technologies

Care Coordination ToolsTelehealth Platforms

Industry Keywords

Transitional CareAcute CarePost-Acute CareComplex Patient ManagementCMS Transitional Care Management GuidelinesJoint Commission Standards

About the role

Key responsibilities & impact

Conduct comprehensive clinical assessments of high-risk patients at discharge and throughout the 30-day transitional care period
Develop, implement, and update individualized patient-centered care plans
Coordinate care and communication among inpatient providers, primary care, specialists, home health agencies, and community resources
Serve as the primary 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 follow-up appointments, home visits, and treatment adherence
Lead and participate in interdisciplinary rounds and case conferences
Monitor patient progress through outreach visits, telehealth, and phone contacts
Intervene when clinical or psychosocial issues arise
Ensure compliance with CMS Transitional Care Management guidelines, Joint Commission standards, and organizational policies through accurate documentation
Participate in quality improvement initiatives and strengthen transitional care workflows and patient outcomes
Perform other duties as assigned

Requirements

What you’ll need

Bachelor of Science in Nursing (BSN) required
Active, unrestricted Registered Nurse (RN) license
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
High-speed internet required
Must live within 1 hour of Mint Hill
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 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

Benefits

Comp & perks

Comprehensive Total Rewards package
Paid Time Off programs
Medical, dental, vision, life, and short- and long-term disability benefits
Flexible Spending Accounts for eligible health care and dependent care expenses
Adoption assistance
Paid parental leave
Defined contribution retirement plans with employer match
Financial wellness programs
Educational Assistance Program
Premium pay such as shift and on-call pay based on role
Incentive pay for select positions
Opportunity for annual performance-based increases
Remote work from home