Transitional Care Management

About the role

Department: 10172 Advocate Aurora Health Corporate - WI

Major Responsibilities

• Conduct comprehensive clinical assessments of high-risk patients at discharge and throughout the 30-day transitional care period, identifying medical, psychosocial, and environmental risk factors.
• Develop, implement, and continuously update individualized, patient-centered care plans addressing clinical needs, medication management, and follow-up care.
• Career coordination, critical thinking, and clinical decision-making skills.
• Coordinate care and facilitate timely communication among inpatient providers, primary care, specialists, home health agencies, and community resources.
• Serve as the primary point of contact for patients and families, providing education on disease management, medications, symptom monitoring, and escalation protocols.
• Manage a caseload of post-discharge patients and ensure completion of follow-up appointments, home visits, and adherence to prescribed treatments.
• Lead and participate in interdisciplinary rounds and case conferences, collaborating with physicians, pharmacists, social workers, behavioral health providers, and nursing staff.
• Maintain patient progress through outreach visits, telehealth, and phone contacts, intervening promptly when clinical or psychosocial issues arise.
• Ensure compliance with CMS Transitional Care Management guidelines, Joint Commission standards, and organizational policies through accurate and timely documentation.
• Participate in quality improvement initiatives and identify opportunities to strengthen transitional care workflows and patient outcomes.

Education

• Bachelor of Science in Nursing (BSN) required.

Work Experience

• Minimum of five years of clinical nursing experience in acute care, discharge planning, post-acute care, or transitional care.
• Minimum of three years of experience providing care and patient education to complex populations, including heart failure, COPD, GI bleed, sepsis, or stroke.

Knowledge / Skills / Abilities

• Advanced clinical expertise in complex patient management and transitional care.
• Strong care coordination, critical thinking, and clinical decision-making skills.
• Demonstrated leadership in interdisciplinary collaboration and patient advocacy.
• Strong communication skills, including use of motivational interviewing techniques.
• Proficiency with electronic health records, care coordination tools, and telehealth platforms.
• Knowledge of regulatory requirements and reimbursement criteria related to transitional care.
• Strong organizational, analytical, and prioritization skills.
• Commitment to ethical practice, patient-centered care, and continuous professional development.

Physical Requirements And Working Conditions

• Primarily remote work environment with occasional on-site meetings.
• Standard schedule is Monday through Friday, 8:00 a.m. – 4:30 p.m., with potential evening or weekend coverage as needed to support patient transitions and caseload requirements.

Preferred Job Requirements

• Education Master of Science in Nursing or related field preferred.
• Certification / Registration / License Preferred certifications include Medical-Surgical RN (MEDSURG-BC), Cardiac-Vascular Nursing (CV-BC), or Nursing Case Management (CMGT-BC).
• Experience Additional experience in transitional care or case management preferred.