Transitional Care Management Registered Nurse

Advocate Aurora Health

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

Posted 10/5/2026part-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 transitional care and complex patient management, with a strong focus on care coordination, patient education, and adherence to regulatory standards. Proficient in utilizing electronic health records and telehealth platforms to enhance patient outcomes and streamline communication among interdisciplinary teams.

Highest-signal resume keywords

Bachelor Of Science In Nursing (BSN)Active Registered Nurse (RN) LicenseFive Years Of Clinical Nursing ExperienceAdvanced Clinical Expertise In Transitional CareStrong Care Coordination Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical AssessmentMedication ManagementPatient-Centered Care PlansDisease Management EducationTelehealth MonitoringDocumentation AccuracyQuality Improvement InitiativesCritical ThinkingClinical Decision-MakingRisk Factor Identification

Soft Skills

Strong Communication SkillsLeadership In Interdisciplinary CollaborationPatient AdvocacyOrganizational SkillsAnalytical Skills

Tools & Technologies

Electronic Health RecordsCare Coordination ToolsTelehealth Platforms

Certifications & Qualifications

Medical-Surgical RN (MEDSURG-BC)Cardiac-Vascular Nursing (CV-BC)Nursing Case Management (CMGT-BC)

Industry Keywords

Transitional Care ManagementCMS GuidelinesJoint Commission StandardsAcute CarePost-Acute Care

About the role

Key responsibilities & impact

Conduct comprehensive clinical assessments of high-risk patients at discharge and throughout the 30-day transitional care period
Identify medical, psychosocial, and environmental risk factors
Develop, implement, and continuously update individualized, patient-centered care plans
Address clinical needs, medication management, and follow-up care
Coordinate care and facilitate communication among inpatient providers, primary care, specialists, home health agencies, and community resources
Serve as the primary point of contact for patients and families
Provide education on disease management, medications, symptom monitoring, and escalation protocols
Manage a caseload of post-discharge patients
Ensure completion of follow-up appointments, home visits, and adherence to prescribed treatments
Lead and participate in interdisciplinary rounds and case conferences
Collaborate with physicians, pharmacists, social workers, behavioral health providers, and nursing staff
Monitor patient progress through outreach visits, telehealth, and phone contacts
Intervene promptly when clinical or psychosocial issues arise
Ensure compliance with CMS Transitional Care Management guidelines, Joint Commission standards, and organizational policies
Maintain accurate and timely documentation
Participate in quality improvement initiatives
Identify opportunities to strengthen transitional care workflows and patient outcomes
Perform other duties and responsibilities 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
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
Must have high-speed internet
Must live in North Carolina within one hour of Mint Hill
Master of Science in Nursing or related field preferred
Preferred certifications include Medical-Surgical RN (MEDSURG-BC), Cardiac-Vascular Nursing (CV-BC), or Nursing Case Management (CMGT-BC)
Additional experience in transitional care or case management preferred

Benefits

Comp & perks

Comprehensive Total Rewards benefits and well-being programs
Premium pay such as shift and on-call pay
Incentive pay for select positions
Opportunity for annual increases based on performance
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 and paid parental leave
Defined contribution retirement plans with employer match
Other financial wellness programs
Educational Assistance Program
Full remote work from home position
Occasional on-site meetings