Transitions of Care Nurse (RN or LPN) - Temporary - Remote

Overview

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.

In Short

• Serve as the primary clinical resource for members discharging from inpatient acute medical facilities.
• Coordinate and manage transitions of care for assigned members.
• Communicate with hospital discharge planners, SNFs, primary care providers, and other services.
• Perform telephonic assessments to evaluate member needs and care barriers.
• Develop individualized care plans based on member health conditions.
• Monitor and document member progress, escalating concerns as needed.
• Educate members and/or caregivers on self-care strategies.
• Track and report outcomes related to care transitions.

Requirements

• Active and unrestricted RN or LPN license in Virginia.
• Must reside in Northern Virginia.
• Minimum of 2 years of recent clinical experience.
• Strong knowledge of discharge planning and transitions of care best practices.
• Experience with managed care plans or care coordination teams preferred.
• Excellent communication and organizational skills.
• Proficient in electronic medical records systems.
• Comfortable working independently in a remote environment.

Benefits

• Competitive pay rate of $43/hour.
• Opportunity to work remotely.
• Engagement in meaningful work that improves health outcomes.
• Supportive work environment focused on care coordination.