Compensation: $85,000 - $95,000
Job Type: Full Time
Job Overview:
Vitae Health Systems is seeking an experienced Care Transitions Utilization Nurse (RN) to manage patient needs during the most critical window of care: the transition out of the post-acute setting. Working alongside embedded nurse practitioners who facilitate discharge planning while patients are in the facility, this role provides telephonic outreach and follow-up for residents who transfer to the emergency department or hospital, as well as residents discharged from the skilled nursing facility to the community or to another post-acute setting, with a focus on safe, well-coordinated transitions and reducing avoidable utilization.
This is a hybrid role, with one day per week in the Park Ridge, IL office, reporting directly to the Executive Director of Value-Based Care Clinical Operations.
Key Responsibilities:
• Identify emergency department visits and hospital admissions through ADT feeds and NP notifications, and complete a structured review of each event, documenting key details and barriers
• Determine the circumstances surrounding each event and discharge 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, building on the discharge plan developed in-house by the embedded NP
• Confirm by telephone that each patient is connected to the appropriate ongoing care, including a community primary care provider where applicable, and has the necessary 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 who show early signs of decline
• Perform telephone assessment and triage using approved protocols to differentiate emergent from non-emergent needs and direct patients to the appropriate resource
• Document each encounter and use SBAR to escalate to an NP, RN, or physician when a call falls outside protocol or clinical judgment requires it
• Maintain accurate review data and prepare trend reports for Clinical Operations; identify patterns in discharges 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 the Vitae VBC and Clinical Operations teams; contribute to SOP development and revision as the program matures
Requirements
• Active, unrestricted RN license in Illinois, or eligibility for a compact license as applicable; responsibilities are performed within the scope of the nurse's license, with escalation as required
• 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
Preferred Qualifications:
• MDS or RAC-CT certification or equivalent experience
• Experience with ACO, value-based care, or care transitions programs, including ACO REACH or LEAD
• Experience with ADT feeds and population health dashboards
• Familiarity with goals of care and advance care planning conversations
• Experience working with nurse practitioners in long term care
• Telephone triage or case management experience
Benefits
• 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
• Competitive salary and benefits package
• Collaborative and supportive work environment
