Offer summary

Qualifications:

Active and unrestricted RN or LPN license in Virginia., Minimum of 2 years of recent clinical experience in a medical or physical health setting., Strong knowledge of discharge planning and transitions of care best practices., Excellent communication, organizational, and critical thinking skills..

Key responsabilities:

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.

Perform telephonic assessments to evaluate member needs and develop individualized care plans.

Educate members and/or caregivers on diagnoses, medications, and self-care strategies to prevent unnecessary readmissions.

Job description

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.

Required profile