Transition of Care Registered Nurse - Field in Northern NJ

Position Summary This role plays a vital part in helping members successfully transition from nursing facilities back into the community. The position focuses on managing incoming referrals for nursing facility transitions, maintaining a strong on‑site presence, and coordinating safe, timely discharges that promote independence and quality of life. The individual will be embedded in assigned nursing facilities 2‑3 days or more per week, based on member needs and acuity, building trusted relationships with facility staff and interdisciplinary teams. Responsibilities include assessing member readiness to return home, facilitating Interdisciplinary Team (IDT) meetings, and developing comprehensive, member‑centered transition plans of care. Rather than carrying a traditional caseload, this role is outcome‑focused, with a monthly goal of successfully transitioning three members from nursing facilities back to the community. The position also requires community follow‑up, meeting members face‑to‑face after discharge to complete a NJ Choice Change in Condition assessment within 10 business days of discharge. In addition, the role participates in workgroup meetings, contributing insights that help improve processes, outcomes, and overall transition success. This position is ideal for someone who thrives in a collaborative environment, values meaningful in‑person engagement, and is passionate about helping members return home safely and confidently. Additional Job Details Utilize workflows, processes, and critical thinking to ensure members remain in community for 6 months post transition. Actively engage in preventive care efforts by scheduling and confirming member appointments, coordinating transportation, and promoting adherence to care plans. Implement strategies to reduce avoidable emergency department visits and hospital admissions through early intervention and education. Provide enhanced member education on in‑home safety measures, including fall prevention and medication adherence. When appropriate, accompany members to medical appointments to support care continuity and ensure understanding of treatment plans. Apply critical thinking and evidence‑based clinical criteria to support contractual rebalancing goals. Support the Health Plan Rebalancing Initiative goal of successful transitions: identify and assess members to transition from the Nursing Facility (NF) setting into the community. Follow up on CM referrals and visit current NF members in‑person twice a week as needed to complete the rebalancing events and assessments. Complete telephonic or in‑person contact as appropriate to assess the home prior to discharge and identify any environmental supports needed to support transition (i.e., ramp, DME installation, etc.). Conduct an in‑person Significant Change Visit with member and Rep if applicable, within 7 business days of transition, coordinate provision of services as needed, establish Plan of Care, and document all actions taken. Contact facility's Business Office once a week to follow‑up on member's census and coordinate with Social Services and CM to facilitate discharge. Work collaboratively with health plan case managers to identify high‑risk community members and implement appropriate interventions to prevent lapse or coordinate safe transition upon receiving referral. Drive enhanced value of health care to increase member satisfaction and retention, and drive new membership growth. Engage in building strong relationships that contribute toward member satisfaction and retention. Required Qualifications Active, unrestricted and good standing RN license in the state of New Jersey. Minimum 2 years of clinical experience. Experience in all or some of the following: Managed Care, Discharge coordination, Transition of care, Home Health, Case Management and Medicaid. Must possess reliable transportation and be willing and able to travel up to 75% of the time within the assigned coverage area of New Jersey. Mileage is reimbursed per our company expense reimbursement policy. Must reside in Northern New Jersey; Warren, Sussex, Morris, Passaic, Bergen, Essex and Hudson Counties. Preferred Qualifications 2 or more years clinical nursing experience in home health, case management and/or discharge planning. Proficiency with computer skills, including navigating multiple systems. Ability to work in a fast‑paced environment. Education Associate Degree Required. BSN preferred. Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $32.01 - $68.55 . This represents the base hourly rate or base annual full‑time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short‑term incentive program in addition to the base pay range listed above. Benefits Great benefits for great people. This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. Benefits include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. EEO Statement Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. #J-18808-Ljbffr