Care Transitions Utilization LPN

Vitae Health Systems

. Identify emergency department visits and hospital admissions through ADT feeds and NP notifications, and complete structured reviews documenting key details and barriers .

Posted 10/20/2026full-timePark Ridge • Illinois • United StatesMid-LevelSenior💰 $65,000 - $75,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in care coordination, discharge planning, and performance improvement within skilled nursing facilities. Proficient in telephone assessment, triage, and documentation, ensuring effective communication and follow-up care for patients.

Highest-signal resume keywords

Active LPN LicenseQAPI ExperienceTelephone Assessment and TriageSkilled Nursing Facility OperationsStrong Documentation and Organization

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Care PlanningChange in Condition ManagementPerformance Improvement ProjectsData-Driven Follow-UpADT FeedsPopulation Health DashboardsSBAR CommunicationHigh-Volume Workflow ManagementTelephone TriageCase Management

Soft Skills

Clinical JudgmentOrganizationFollow-ThroughCommunication

Tools & Technologies

EMR SystemsSpreadsheetsDropdown-Based Review Tools

Certifications & Qualifications

MDS CertificationRAC-CT Certification

Industry Keywords

Value-Based CareACOCare Transitions ProgramsGoals of CareAdvance Care Planning

About the role

Key responsibilities & impact

Identify emergency department visits and hospital admissions through ADT feeds and NP notifications, and complete structured reviews documenting key details and barriers
Determine circumstances surrounding events and discharges through chart review and provider discussion
Escalate cases to clinical leadership when defined triggers are met
Conduct telephonic outreach following discharge to the community or another post-acute setting
Confirm patients are connected to appropriate ongoing care, follow-up care, medications, and resources
Coordinate with facility staff, community providers, and caregivers to close care gaps
Escalate patients who cannot be connected or show early signs of decline
Perform telephone assessment and triage using approved protocols
Document encounters and use SBAR to escalate to an NP, RN, or physician when needed
Maintain accurate review data and prepare trend reports for Clinical Operations
Identify discharge patterns and support case-based learning and focused deep-dive reviews
Apply QAPI methods to design, test, and track performance improvement projects, and report results to leadership
Partner with embedded NPs, facility nursing leadership, and Vitae VBC and Clinical Operations teams
Contribute to SOP development and revision as the program matures
Report directly to the Executive Director of Value-Based Care Clinical Operations

Requirements

What you’ll need

Active, unrestricted LPN license in Illinois, or eligibility for a compact license as applicable
Five or more years of skilled nursing facility experience in a leadership or advanced role, such as ADON, unit manager, shift supervisor, or MDS coordinator
Working knowledge of SNF operations, Part A skilled stays, change in condition management, care planning, facility discharge processes, and SBAR communication methods
Hands-on QAPI experience, including root cause analysis, performance improvement projects, and data-driven follow-up
Demonstrated clinical judgment and comfort with telephone assessment and triage
Strong documentation, organization, and follow-through, with the ability to manage a high-volume workflow independently
Proficiency with EMR systems, spreadsheets, and dropdown-based review tools
Ability to work in a primarily computer and phone-based environment, including prolonged sitting and extended phone use, while managing multiple competing priorities
Periodic travel to partner facilities
MDS or RAC-CT certification or equivalent experience preferred
Experience with ACO, value-based care, or care transitions programs, including ACO REACH or LEAD preferred
Experience with ADT feeds and population health dashboards preferred
Familiarity with goals of care and advance care planning conversations preferred
Experience working with nurse practitioners in long term care preferred
Telephone triage or case management experience preferred

Benefits

Comp & perks

Competitive salary and benefits package
Collaborative and supportive work environment
Opportunity to play a meaningful role in advancing value-based care for a high-need Medicare population
Be part of a rapidly growing organization with a commitment to excellence in healthcare
Help build clinical programs and SOPs as the care transitions program matures