Job Title: Transitions of Care Nurse (RN or LPN)
Location: Remote (Must Reside in Northern Virginia)
Pay Rate: $43/hour
Employment Type: Temporary Assignment
Industry: National Managed Care Organization
Position Summary:
We are seeking an experienced and compassionate Transitions of Care Nurse (RN or LPN) to support members during the critical phase of transitioning from an acute care setting to home or a skilled nursing facility (SNF). This remote position plays a key role in improving health outcomes and reducing hospital readmissions by ensuring members receive coordinated, timely, and effective post-discharge support.
Candidates must reside in Northern Virginia, as local knowledge of healthcare facilities and community resources is essential for success in this role.
Key Responsibilities:
• Serve as the primary clinical resource for members discharging from inpatient acute medical facilities.
• Coordinate and manage transitions of care for assigned members, ensuring timely follow-up and adherence to discharge plans.
• Communicate with hospital discharge planners, SNFs, primary care providers, specialists, home health agencies, and other community-based services to ensure appropriate care continuity.
• Perform telephonic assessments to evaluate member needs, medication compliance, care barriers, and social determinants of health.
• Develop and implement individualized care plans based on member health conditions, discharge instructions, and support system availability.
• Monitor and document member progress, escalating concerns to the interdisciplinary care team when needed.
• Educate members and/or caregivers on diagnoses, medications, and self-care strategies to prevent unnecessary readmissions.
• Track and report outcomes related to care transitions and provide input for quality improvement initiatives.
Required Qualifications:
• Active and unrestricted RN or LPN license in the state of Virginia.
• Must reside in Northern Virginia.
• Minimum of 2 years of recent clinical experience in a medical or physical health setting (e.g., inpatient hospital, SNF, or home health).
• Strong knowledge of discharge planning and transitions of care best practices.
• Experience working with managed care plans, Medicare/Medicaid populations, or care coordination teams is preferred.
• Excellent communication, organizational, and critical thinking skills.
• Proficient in electronic medical records (EMR) systems and Microsoft Office applications.
• Comfortable working independently in a remote environment and managing time effectively.