Transition of Care – Registered Nurse

CVS Health

. Complete market-specific post-discharge assessments, 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 team collaboration 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

Clinical Practice ExperienceMedication ManagementHealth Related Social Needs AssessmentSocial Determinants of HealthCondition Management EducationMedication ReconciliationPrior AuthorizationCommunity Resource CoordinationData ReportingCare Plan Development

Soft Skills

Analytical SkillsProblem-Solving SkillsEffective CommunicationOrganizational SkillsInterpersonal Skills

Tools & Technologies

Microsoft Office SuiteWordExcelOutlookOneNoteTeamsVirtual Collaboration Tools

Certifications & Qualifications

Registered Nurse (RN) LicenseCertified Case Manager

Industry Keywords

Care ManagementHome Health Care CoordinationLTSSHCBSHealth EquityCultural CompetencyPublic BenefitsNCQA Standards

About the role

Key responsibilities & impact

Complete market-specific post-discharge assessments, 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 address barriers to optimal member health
Apply strategies to reduce member risk
Lead and coordinate Interdisciplinary Care Team meetings to develop and implement Individualized Care Plans
Coordinate care with interdisciplinary teams to support optimal member wellness
Coordinate post-discharge meal delivery, secure durable medical equipment, and ensure timely physician follow-up
Educate members and caregivers about care plans, medications, and community resources
Explain payer and plan benefits, policies, and procedures to providers, members, and personnel
Update care plans based on changes in condition or behavioral health status
Review prior claims for potential impacts on case management and eligibility
Complete outreach calls and post-discharge questionnaires within compliance timelines
Schedule follow-up appointments and complete medication reconciliation
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 care team 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 or willingness to obtain
3+ years of clinical practice experience
1+ year of experience in care coordination or working with high-risk populations
Proficiency in Microsoft Office Suite, including Word, Excel, Outlook, OneNote, and Teams
Confidence working at home and independently, using virtual collaboration tools
Access to a private, dedicated workspace
Associate’s Degree in Nursing (required)
Certified Case Manager preferred
3+ years of 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, cultural competency, community-based services, and public benefits preferred
Bilingual preferred
Excellent analytical and problem-solving skills preferred
Effective communication, organizational, and interpersonal skills preferred
Ability to work independently, multitask, prioritize, and adapt to a fast-paced changing environment preferred
Must comply with state and federal regulations, including NCQA standards

Benefits

Comp & perks

Medical coverage
Dental coverage
Vision coverage
Paid time off
Retirement savings options
Wellness programs
CVS Health bonus, commission or short-term incentive program
Comprehensive benefits package supporting physical, emotional, and financial well-being
Remote work from home