Transition of Care Management - Registered Nurse

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Help us elevate our member care to a whole new level! Join our Aetna team as an industry leader in serving dual eligible populations by utilizing best-in-class operating and clinical models. You can have life-changing impact on our Fully Integrated Dual Eligible Plan (FIDE) members, who are enrolled in Medicare and Medicaid and present with a wide range of complex health and social challenges. With compassionate attention and excellent communication, we collaborate with members, providers, and community organizations to address the full continuum of our members' health care and social determinant needs. Join us in this exciting opportunity as we grow and expand to change lives in new markets across the country. The Transition of Care CM plays a critical role in ensuring that our high-risk, medically complex, and vulnerable members—those enrolled in HIDE/FIDE SNP and other Medicaid waiver programs—experience safe, effective, and seamless transitions across care settings. The TOC CM ensures the member experiences a seamless transition to their next care setting. This includes members undergoing significant changes in health status that result in emergency department visits, inpatient admissions, or stays in skilled nursing or rehabilitative facilities. This position provides comprehensive care coordination, assists with the development and implementation of care plans, facilitates communication with interdisciplinary teams, and supports members and families to reduce readmissions, promote health equity and improve health outcomes. Through person-centered planning and timely interventions, the TOC CM ensures that all necessary care, supports, and services are in place at discharge to maintain continuity of care and support optimal recovery.

Complete a market specific post discharge assessment to identify member’s needs, including Health Related Social Needs and Social Determinants of Health (SDoH). Providing comprehensive discharge planning, including facilitating transitions of care between institutional and community settings, ensuring continuity and quality of care. Ensuring the member has filled/received their medication(s) and has an understanding on how to take their ordered medications. Providing clinical assistance to determine appropriate services and supports due to member’s health needs (including but not limited to: Prior Authorizations, Coordination with PCP and Specialty providers, Condition Management information and education, Medication management, Community Resources and supports) Identifying and engaging barriers to achieving optimal member health Utilizing discretion to apply strategies to reduce member risk Lead and coordinate the Interdisciplinary Care Team (ICT) to develop and implement Individualized Care Plans (ICPs). Facilitating overall care coordination with the care team to ensure member achieves optimal wellness within the confines of the member’s condition(s) and abilities to self-manage Coordinating post-discharge meal delivery, assists with securing DME, and helps to ensure timely physician follow-up Provide education to members and caregivers on care plans, medications, and available community resources, as needed. Understanding Payer/Plan benefits, policies, procedures, and articulating them effectively to providers, members, and other key personnel Updating the Care Plan for any change in condition or behavioral health status Our TOC Coaches are frontline advocates for members who cannot advocate for themselves. The TOC team will review prior claims to address potential impact on current case management and eligibility status. Assessments and/or questionnaires are designed to use a holistic approach to identify the need for a referral to clinical resources for assistance in functionality. Responsibilities: Responsible for completing outreach cadence calls and post-discharge questionnaires within required compliance driven timelines. Schedule follow-up appointments and ensure medication reconciliation is completed. Identify and address barriers to care such as transportation, housing, or access to medications. Utilizes weekly and daily reporting to identify utilization for the purpose of reducing Emergency Department Utilization and 30-day hospital readmissions. Follows members identified as inpatient in hospitals (whether planned or unplanned admission) and then throughout the subsequent care continuum until member can return to prior level of functioning in the community. Facilitates Interdisciplinary Care Team Meetings with Social Services, Care Management, PCP and other key players to discuss service needs and support safe transitions. Ensure compliance with state and federal regulations, including NCQA standards.