Registered Nurse – Transition of Care

CVS Health

. Complete market-specific post-discharge assessments to identify member needs, including Health Related Social Needs and Social Determinants of Health .

Posted 10/16/2026full-timeRemote • Illinois • United StatesMid-LevelSenior💰 $66,575 - $142,576 per yearWebsite

About the role

Key responsibilities & impact

Complete market-specific post-discharge assessments to identify member needs, including Health Related Social Needs and Social Determinants of Health
Provide comprehensive discharge planning and facilitate transitions between institutional and community settings
Ensure members have received medications and understand how to take them
Determine appropriate services and supports, including prior authorizations, provider coordination, condition management education, medication management, and community resources
Identify barriers to optimal member health and apply strategies to reduce member risk
Lead and coordinate Interdisciplinary Care Teams to develop and implement Individualized Care Plans
Coordinate care with interdisciplinary teams to support optimal wellness and self-management
Coordinate post-discharge meal delivery, secure durable medical equipment, and ensure timely physician follow-up
Educate members and caregivers on care plans, medications, and community resources
Explain payer and plan benefits, policies, and procedures to providers, members, and personnel
Update care plans when conditions or behavioral health status change
Review prior claims and assessments to identify case management, eligibility, and clinical resource needs
Complete outreach cadence calls and post-discharge questionnaires within compliance timelines
Schedule follow-up appointments and complete medication reconciliation
Identify and address barriers such as transportation, housing, and medication access
Use weekly and daily reporting to reduce emergency department utilization and 30-day hospital readmissions
Follow members from inpatient admission through the care continuum until return to prior community functioning
Facilitate interdisciplinary meetings with Social Services, Care Management, PCPs, and other stakeholders
Ensure compliance with state and federal regulations, including NCQA standards

Requirements

What you’ll need

Active and unrestricted Registered Nurse (RN) License in Illinois
3+ years of clinical practice experience
1+ year(s) of experience in care coordination or working with high-risk populations
Proficient in Microsoft Office Suite, including Word, Excel, Outlook, OneNote, and Teams
Confidence working at home / independent thinker, using tools to collaborate and connect with teams virtually
Access to a private, dedicated space to conduct work effectively
Associate’s Degree in Nursing (REQUIRED)
Working knowledge of LTSS and HCBS options, chronic disease management, medication side effects, health equity and cultural competency, community-based services and public benefits
Excellent analytical and problem-solving skills
Effective communications, organizational, and interpersonal skills
Ability to work independently, multitask, prioritize, and adapt to a fast-paced changing environment
Must have or be able to obtain a direct/hardwired internet connection within 7 feet of the computer, with minimum speeds of 25 Mbps download and 3 Mbps upload
WiFi and satellite internet are not permitted
Quiet, secure, private designated home work location compliant with CVS Health and HIPAA guidelines
Must work within the state and city where currently residing
Must provide own workspace furniture
Comfortable setting up and using multiple monitors and navigating multiple applications
Ability to use email, calendar invites, Teams messaging, and virtual meetings
Experience with Microsoft Office 365 applications or similar Google Workspace tools
Ability to access secure systems such as VPN and EHR portals, lock computer screens, manage strong passwords, and recognize suspicious emails or links
Ability to troubleshoot common technical issues independently
Openness to learning new skills
Bilingual is preferred
Certified Case Manager is preferred
Bachelor’s Degree in Nursing is preferred

Benefits

Comp & perks

CVS Health bonus, commission or short-term incentive program in addition to base pay
Medical coverage
Dental coverage
Vision coverage
Paid time off
Retirement savings options
Wellness programs
Other resources supporting physical, emotional, and financial well-being
Company-provided equipment including keyboard, monitor, computer, headset, etc.