The Transition of Care (TOC) Registered Nurse is telephonic and is responsible for coordinating and managing care for members transitioning from observation, inpatient, skilled nursing, and other post-acute settings. The RN works collaboratively with patients, caregivers, providers, Community Health Workers, and interdisciplinary teams to support safe transitions, address barriers to recovery, reduce avoidable hospital readmissions and emergency department utilization, and improve overall health outcomes.
Candidate must live and possess an active and unrestricted Utah RN license
If you are located in Utah, you will have the flexibility to work remotely* as you take on some tough challenges.
Primary Responsibilities:- Assess, develop, implement, and monitor individualized care plans for discharged acute care patients and high-risk Medicare Advantage patients
- Manage a caseload and conduct comprehensive clinical assessments to identify medical, functional, psychosocial, and environmental factors that may impact recovery and health outcomes
- Complete timely outreach to eligible patients following hospitalization, emergency department visits, or post-acute care stays in accordance with organizational standards
- Evaluate discharge plans and address barriers that may interfere with recovery, treatment adherence, or successful transition to the community
- Perform medication reconciliation and identify potential medication-related concerns requiring intervention or provider follow-up
- Engage patients and caregivers in care planning, provide education, and promote self-management to support successful transitions and improved outcomes
- Coordinate care across healthcare settings and providers, including primary care providers, specialists, hospitals, skilled nursing facilities, home health agencies, and community resources
- Collaborate with Community Health Workers and interdisciplinary team members to address social determinants of health and other non-clinical barriers impacting care
- Facilitate timely primary care, specialty care, and post-discharge follow-up appointments, if indicated
- Monitor patient progress throughout the transition period and modify interventions as necessary to address changing needs
- Identify patients at risk for avoidable emergency department utilization, hospital readmissions, or adverse outcomes and implement appropriate interventions
- Communicate and collaborate effectively with patients, caregivers, providers, and interdisciplinary teams to ensure continuity of care
- Maintain accurate, timely, and complete documentation in accordance with organizational, regulatory, and accreditation requirements
- Adhere to all applicable policies, procedures, HIPAA regulations, and quality standards
- Participate in performance improvement, care coordination, and population health initiatives designed to improve member outcomes and reduce healthcare utilization
- Perform other duties as assigned
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:- Current, unrestricted Registered Nurse (RN) license in Utah
- 3+ years of clinical nursing experience, preferably in acute care, care management, case management, utilization management, discharge planning, or transitional care
- Experience working within managed care, Medicare Advantage, value-based care, care management, or population health environments
- Demonstrates case management knowledge and ability to independently assess member needs, develop care plans, prioritize interventions, and manage complex cases with minimal supervision
- Solid clinical assessment, critical thinking, problem-solving, and decision-making skills
- Excellent written, verbal, and interpersonal communication skills
- Ability to collaborate effectively with providers, hospitals, skilled nursing facilities, Community Health Workers, and interdisciplinary care teams
- Proficiency with electronic medical records, case management systems, and Microsoft Office applications
- Valid, unrestricted driver's license, reliable transportation, current automobile insurance, and acceptable driving record
Preferred Qualifications:
- Bachelor's degree in nursing (BSN)
- Case Management Certification (CCM, ACM-RN, or equivalent)
- Experience supporting transitions of care, readmission prevention, post-acute care management, or emergency department utilization programs
- Knowledge of community resources and social determinants of health
Key Performance Indicators:- Meets outreach and engagement goals for assigned members
- Completes initial outreach and assessments within established timeframe
- Maintains member engagement throughout the transition period
- Facilitates timely follow-up care and coordination of services
- Supports reduction in avoidable readmissions and emergency department utilization
- Identifies and addresses barriers to successful care transitions
- Collaborates effectively with Community Health Workers, providers, and interdisciplinary teams
- Maintains timely and accurate documentation
- Meets productivity and quality performance standards
- Contributes to improved member outcomes and care experience
*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy.
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $72,800 - $130,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.
