Care Transitions Nurse

Advocate Health Care is proud to be a part of Advocate Health, the third-largest nonprofit integrated health system in the U.S. Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin and Michigan, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs nearly 162,000 team members across 68 hospitals and over 1,000 care locations, and offers one of the nation’s largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides nearly $5 billion in annual community benefits.

Part Time Care Transitions Nurse - This is a part-time remote role that requires high-speed internet and requires some evening and weekend coverage. Care Transitions role for both 30 and 90-day programs Medicare/ACO patient population/Medicare FFS program post-hospital discharge. This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.

Responsible for ensuring an efficient and coordinated hospital discharge and transition process for patients recently hospitalized or treated in the emergency room that are at high risk for increased use of healthcare resources. Accountabilities: Identifies the needs of patients and families and coordinates internal and external community resources within the first month of hospital discharge.