RN - Transition of Care Nurse

Responsibilities

Prominence Health is a value‑based care organization bridging the gap between affiliated health systems and independent providers, building trust and collaboration between the two. The organization creates value for populations and providers to strengthen integrated partnership, advance market opportunities, and improve outcomes for patients and members. Founded in 1993, Prominence Health started as a health maintenance organization (HMO) and was acquired by a subsidiary of Universal Health Services, Inc.

(UHS) in 2014. It serves members, physicians, and health systems across Medicare, Medicare Advantage, Accountable Care Organizations, and commercial payer partnerships, and is committed to transforming healthcare delivery by improving outcomes while controlling costs and enhancing the patient experience.

The Transitional Care (TOC) Nurse is responsible for managing a member’s successful transition from hospital to home and for developing, implementing, and evaluating comprehensive transitional care interventions for high‑risk medical and/or surgical members for Prominence Health Plan. The nurse facilitates the post‑acute care of members at risk for poor health outcomes, frequent emergency room visits, and hospital readmissions, and coordinates care across the continuum.

Key aspects of the program protocols are based upon inpatient and post‑discharge workflows, including bedside visits, member and family education, medication reconciliation, functional assessment, and coordination of post‑discharge appointments and services.

The TOC nurse identifies hospitalized high‑risk, complex members for program enrollment and communicates with all entities involved in the care of the member to promote and maximize care coordination. Upon discharge, the nurse may perform home visits and schedule periodic telephonic follow‑up for 30 days, ensuring medication adherence, managing disease states, identifying gaps in care, and supporting self‑care capabilities.

• Loan Forgiveness Program
• Challenging and rewarding work environment
• Competitive compensation & generous paid time off
• Excellent medical, dental, vision, and prescription drug plans
• 401(k) with company match and discounted stock plan
• SoFi student loan refinancing program
• Career development opportunities within UHS and its 300+ subsidiaries
• More information is available on our benefits guest website:

One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. UHS operates acute care hospitals, behavioral health facilities, outpatient facilities, and ambulatory care access points, an insurance offering, a physician network, and various related services located throughout the United States, Washington, D.C., Puerto Rico, and the United Kingdom.

Visit  for more information.

• Registered Nurse with a BSN or MSN degree; OR a bachelor’s or master’s degree in Public Health or a related field.
• Active, unrestricted, current, and valid Registered Nurse license in the state(s) of practice (Nevada, Texas, and/or Florida).
• Certified Case Manager (CCM) or Certified Professional in Healthcare Quality (CPHQ) preferred.
• Minimum of three (3) years of case management/transition of care experience in a managed care environment required.
• Recent (within past 3 years) working knowledge of Milliman Care Guidelines preferred.
• Minimum of three years in clinical medical/surgical nursing practice within a hospital setting preferred.
• Ability to effectively communicate in English and Spanish, both verbally and in writing required.
• Proficiency in gathering and interpreting empirical evidence, formulating recommendations, action plans, and interventions to improve overall organizational strategy.
• Demonstrated ability to work independently with minimal supervision and maintain effective collaborative working relationships with staff.
• Strong project management skills, detail‑oriented, and able to assimilate and analyze a wide variety of information under deadline…