Transitional Care Management Nurse (RN) - Care Transitions PT

This is a salaried exempt position.

Must be within a hour of Mint Hill Primary Care

This is a remote position that requires high speed internet

• →Conduct comprehensive clinical assessments of high‑risk patients at discharge and throughout the 30‑day transitional care period, identifying medical, psychosocial, and environmental risk factors.
• →Develop, implement, and continuously update individualized, patient‑centered care plans addressing clinical needs, medication management, and follow‑up care.
• →Coordinate care and facilitate timely communication among inpatient providers, primary care, specialists, home health agencies, and community resources.
• →Serve as the primary point of contact for patients and families, providing education on disease management, medications, symptom monitoring, and escalation protocols.
• →Manage a caseload of post‑discharge patients and ensure completion of follow‑up appointments, home visits, and adherence to prescribed treatments.
• →Lead and participate in interdisciplinary rounds and case conferences, collaborating with physicians, pharmacists, social workers, behavioral health providers, and nursing staff.
• →Monitor patient progress through outreach visits, telehealth, and phone contacts, intervening promptly when clinical or psychosocial issues arise.
• →Ensure compliance with CMS Transitional Care Management guidelines, Joint Commission standards, and organizational policies through accurate and timely documentation.
• →Participate in quality improvement initiatives and identify opportunities to strengthen transitional care workflows and patient outcomes.
• →Perform other duties and responsibilities as assigned.

• Bachelor of Science in Nursing (BSN) required.

• Master of Science in Nursing or related field preferred.

• Active, unrestricted Registered Nurse (RN) license.

• Preferred certifications include Medical‑Surgical RN (MEDSURG‑BC), Cardiac‑Vascular Nursing (CV‑BC), or Nursing Case Management (CMGT‑BC).

• 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.

• Not required beyond minimum qualifications.

• Primarily remote work environment with occasional on‑site meetings.
• Standard schedule is Monday through Friday, 8:00 a.m. – 4:30 p.m., with potential evening or weekend coverage as needed to support patient transitions and caseload requirements.

• Additional experience in transitional care or case management preferred.

All responsibilities and requirements are subject to possible modification to reasonably accommodate individuals with disabilities.
This job description does not state or imply that these are the only duties to be performed. Employees may be required to perform other job‑related duties as requested.

Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including:

Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation’s largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits.