Transition of Care II, RN

Job Summary

The Transitions of Care Registered Nurse II (TOC RN II) serves as an experienced clinical care coordinator responsible for managing members with moderate to highly complex medical, behavioral, and psychosocial needs during transitions across the continuum of care. In addition to providing comprehensive transitions of care services, the TOC RN II functions as a clinical resource and mentor to nursing staff, supports quality improvement initiatives, and assists leadership in promoting evidence-based practices, regulatory compliance, and operational excellence.

Functions & Job Responsibilities

• Perform comprehensive clinical assessments for members experiencing complex transitions of care following inpatient admissions, emergency department visits, skilled nursing facility stays, rehabilitation services, and other qualifying events.

• Independently manage a complex caseload requiring advanced clinical assessment, critical thinking, and interdisciplinary care coordination.

• Develop, implement, evaluate, and revise individualized transition care plans based on member needs, clinical priorities, evidence-based guidelines, and member goals.

• Complete medication reconciliation, identify complex medication-related concerns, collaborate with providers and pharmacists, and recommend interventions that promote medication safety and adherence.

• Cook up services across hospitals, physician practices, skilled nursing facilities, behavioral health providers, home health agencies, pharmacies, hospice, palliative care, and community-based organizations.

• Identify members at high risk for readmission, adverse clinical outcomes, or care fragmentation and implement advanced care coordination strategies.

• Serve as a clinical resource for Transitions of Care Registered Nurse I staff by providing guidance on clinical decision-making, documentation standards, care planning, and complex case management.

• Mentor newly hired nurses through clinical coaching, knowledge sharing, and support of departmental orientation activities.

• Participate in interdisciplinary care team (ICT) meetings and provide clinical recommendations that support safe, effective, and member-centered care.

• Collaborate with Medical Directors, Utilization Management, Complex Case Management, Social Work, Pharmacy, Behavioral Health, Quality Improvement, and Provider Relations to resolve complex clinical issues.

• Analyze clinical trends and identify opportunities to improve care coordination, transitions of care workflows, and member outcomes.

• Participate in departmental quality improvement initiatives, process improvement projects, regulatory readiness activities, and corrective action plans.

• Review documentation for accuracy, completeness, and regulatory compliance while promoting documentation best practices.

• Aid leadership in identifying workflow improvements that enhance operational efficiency and member experience.

• Assess social determinants of health and coordinate interventions that address barriers impacting successful care transitions.

• Educate members and caregivers regarding disease management, medication adherence, discharge instructions, preventive care, and self-management strategies.

• Promote culturally competent, trauma-informed, and person-centered care while supporting organizational health equity initiatives.

• Maintain compliance with CMS Medicare Advantage regulations, NCQA accreditation standards, HIPAA requirements, organizational policies, and applicable state and federal regulations.

• Support achievement of departmental productivity, quality, and member satisfaction goals.

• Maintain current clinical knowledge through continuing education and professional development.

• Perform additional duties within the scope of licensure as assigned.

Qualifications

• Licensures and Certifications: Active, unrestricted California RN license. Minimum of four (4) years of progressive clinical nursing experience. Minimum of two (2) years of experience in Care Management, Case Management, Utilization Management, Population Health, Managed Care, Transitional Care, or related clinical specialty. Demonstrated experience managing members with complex medical, behavioral health, and psychosocial needs. Experience participating in quality improvement initiatives, clinical mentoring, or project work preferred. Medicare Advantage or health plan experience required. Certified Case Manager (CCM), Accredited Case Manager (ACM), or other nationally recognized case management certification preferred.

• Skills: Advanced knowledge of Medicare Advantage regulations, CMS requirements, NCQA accreditation standards, HEDIS, Star Ratings, and population health principles. Advanced clinical assessment and critical thinking skills with the ability to manage medically complex members. Strong knowledge of care coordination, transitions of care, chronic disease management, utilization management, and interdisciplinary care planning. Ability to independently prioritize competing clinical demands while managing a complex caseload. Demonstrated ability to mentor, coach, and support clinical staff in the application of evidence-based practices. Excellent verbal, written, and interpersonal communication skills with the ability to effectively collaborate across multidisciplinary teams. Strong analytical skills with the ability to identify trends, recommend process improvements, and support quality initiatives. Proficiency using electronic health records, care management platforms, Microsoft Office Suite, and healthcare technology applications. Ability to analyze clinical documentation and ensure compliance with regulatory and organizational standards. Strong organizational and project management skills. Demonstrated commitment to quality improvement, health equity, member advocacy, and continuous professional development. Bilingual in Mandarin/Cantonese, Vietnamese, Korean, or Spanish preferred.

Physical & Working Environment

• Physical requirements needed to perform the essential functions of the job, with or without reasonable accommodation: Must be able to travel when needed or required Ability to operate a keyboard, mouse, phone and perform repetitive motion (keyboard); writing (note-taking) Ability to sit for long periods; stand, sit, reach, bend, lift up to fifteen (15) lbs. Ability to express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly. Work is performed in an office environment and/or remotely.