Transition of Care Nurse (RN)

About the role

Prominence Health is a value-based care organization dedicated to improving health outcomes through integrated partnerships. Founded in 1993, Prominence Health began as an HMO and was acquired by UHS in 2014. It serves members, physicians, and health systems across various payers including Medicare, Medicare Advantage, ACOs, and commercial partners. Prominence Health aims to transform healthcare delivery by controlling costs, enhancing patient experience, and improving health outcomes.

Responsibilities

• Manage a member's successful transition from an acute or post-acute level of care to home.
• Develop, implement, and evaluate comprehensive transitional care interventions for high-risk medical and/or surgical members.
• Facilitate the post-acute care of members at risk for poor health outcomes, frequent ER visits, and hospital readmissions.
• Identify hospitalized high-risk, complex members for program enrollment and communicate with all entities involved in the care of the member to promote and maximize care coordination.
• Inpatient/SNF workflow: Visit members at the bedside, educate members and caregivers about disease states and self-care, identify member-level concerns regarding discharge, and anticipate potential gaps in care.
• Post-discharge workflow: Conduct scheduled telephonic follow-ups for 30 days and in-person visits when appropriate. Focus on medication reconciliation, adherence, management of quality of life and functionality, management of acute and chronic disease states, identification and rectification of gaps in care, support of member’s ability to perform self-care, coordination of post-discharge appointments and services, and coordination of care across the care continuum.
• Adhere to CMSA Standards of Practice for Case Management.
• Contribute to the development of the plan of care of members in Care Management.
• Participate in efforts associated with the successful operation of the SNP CM program and ensure the model of care (MOC) meets or exceeds regulatory and accreditation requirements for CMS, state Medicaid offices (as relevant), and NCQA.

Requirements

• Education: Associate or Bachelor’s Degree in Nursing, required.
• Experience: Minimum of three (3) years in clinical nursing practice, required. Minimum of three (3) years of Case Management/Transition of Care experience in a managed care outpatient or community environment, preferred.
• Recent working knowledge of Milliman Care Guidelines, preferred.
• License & Certifications: Active, unrestricted, current, and valid Registered Nurse licenses in the States of Practice (Nevada, Texas and/or Florida), required. Certified Case Manager (CCM), Case Management Nurse – Board Certified (CMGT-BC), Accredited Case Manager – RN (ACM-RN), or Certified Managed Care Nurse (CMCN), preferred.
• Skills: Experience working with the Medicare and Medicaid population segment, preferred. Knowledge of Medicare/ Medicaid processes and compliance standards, preferred. Ability to effectively communicate in English (Nevada, Texas, and Florida markets). Preferred Spanish (Texas and Florida markets), and/or Spanish, French Creole, and/or Tagalog (Florida market), both verbally and in writing depending on the State of RN licensure and employment location, preferred.

Qualifications

• Education: Associate or Bachelor’s Degree in Nursing, required.
• Experience: Minimum of three (3) years in clinical nursing practice, required. Minimum of three (3) years of Case Management/Transition of Care experience in a managed care outpatient or community environment, preferred.
• Recent working knowledge of Milliman Care Guidelines, preferred.
• License & Certifications: Active, unrestricted, current, and valid Registered Nurse licenses in the States of Practice (Nevada, Texas and/or Florida), required. Certified Case Manager (CCM), Case Management Nurse – Board Certified (CMGT-BC), Accredited Case Manager – RN (ACM-RN), or Certified Managed Care Nurse (CMCN), preferred.
• Skills: Experience working with the Medicare and Medicaid population segment, preferred. Knowledge of Medicare/ Medicaid processes and compliance standards, preferred. Ability to effectively communicate in English (Nevada, Texas, and Florida markets). Preferred Spanish (Texas and Florida markets), and/or Spanish, French Creole, and/or Tagalog (Florida market), both verbally and in writing depending on the State of RN licensure and employment location, preferred.