Transition of Care Management – Registered Nurse

CVS Health

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

Posted 10/5/2026full-timeRemote • Illinois • United StatesMid-LevelSenior💰 $66,575 - $142,576 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in care coordination, discharge planning, and managing high-risk populations while ensuring compliance with state and federal regulations. Proficient in developing individualized care plans and facilitating interdisciplinary care teams to optimize member health outcomes.

Highest-signal resume keywords

Registered Nurse (RN) LicenseCare Coordination ExperienceDischarge PlanningChronic Disease ManagementCertified Case Manager

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Care ManagementMedication ReconciliationHealth EquityCultural CompetencyCommunity-Based ServicesPublic BenefitsAnalytical SkillsProblem-Solving Skills

Soft Skills

Effective CommunicationOrganizational SkillsInterpersonal SkillsIndependent ThinkingMultitasking

Tools & Technologies

Microsoft Office SuiteWordExcelOutlookOneNoteTeams

Certifications & Qualifications

Certified Case Manager

Industry Keywords

Health Related Social NeedsSocial Determinants of HealthInterdisciplinary Care TeamsLTSSHCBSEmergency Department Utilization30-Day Hospital ReadmissionsNCQA Standards

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 and engage barriers to optimal member health
Apply strategies to reduce member risk
Lead and coordinate Interdisciplinary Care Teams to develop and implement Individualized Care Plans
Coordinate care with the care team to support optimal wellness
Coordinate post-discharge meal delivery, secure durable medical equipment, and support timely physician follow-up
Educate members and caregivers on care plans, medications, and community resources
Explain payer/plan benefits, policies, and procedures to providers, members, and key personnel
Update care plans when conditions or behavioral health status change
Complete outreach calls and post-discharge questionnaires within compliance timelines
Schedule follow-up appointments and complete medication reconciliation
Address barriers such as transportation, housing, and medication access
Use daily and weekly 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 care team meetings
Ensure compliance with state and federal regulations, including NCQA standards

Requirements

What you’ll need

Active and unrestricted Registered Nurse (RN) License in Illinois or willing to obtain
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
Certified Case Manager preferred
3+ years Care Management, Discharge Planning and/or Home Health Care Coordination experience preferred
Working knowledge of LTSS and HCBS options, chronic disease management, medication side effects, health equity and cultural competency, community-based services and public benefits preferred
Excellent analytical and problem-solving skills preferred
Effective communications, organizational, and interpersonal skills preferred
Ability to work independently, multitask, prioritize, and adapt to a fast-paced changing environment preferred
Bilingual preferred
Associate’s Degree in Nursing (REQUIRED)
Bachelor’s Degree in Nursing (PREFERRED)
Active and unrestricted Registered Nurse (RN) License in Illinois or willing to obtain

Benefits

Comp & perks

Medical coverage
Dental coverage
Vision coverage
Paid time off
Retirement savings options
Wellness programs
Other resources supporting physical, emotional, and financial well-being
CVS Health bonus, commission or short-term incentive program in addition to base pay