Transition of Care CM - Registered Nurse

About the Role

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.

We do it all with heart, each and every day.

CVS Aetna takes a team‑based approach to providing outstanding patient care. A Transitional Care Manager (TCM) is an integral part of the team, the primary member of the CVS Health clinical care team and facilitator of interdisciplinary collaboration and care continuity across care settings and systems. The TCM empowers the patient and/or caregiver to play an active and informed role in post‑ED/Observation and post‑hospitalization care plan execution.

The TCM role is to support members and staff in transition from care settings, through discharge planning processes, including identifying and addressing barriers, and building relationships with providers and care teams across various sites of care (e.g. ED, hospital, SNF, primary care clinics). This role prioritizes the relationship with the member/family and inpatient facility; it provides high‑quality, member‑centered care; it prevents avoidable readmissions;

and it manages efficient resource utilization.

We are recruiting TCMs who would be available to work either in the OKC or Tulsa metro areas. This position would be hybrid.

• Manage members through transitions of care, either face‑to‑face in the facility or telephonically, within a defined geographical area and care setting.
• Advocate for the member throughout the care continuum to ensure access to resources and resolve all barriers to care.
• Identify opportunities for improved program workflows, increased internal and external partnerships, and higher quality member care.
• Maintain real‑time and accurate records of member status through care transitions within CVS Health’s internal inpatient platform.
• Adhere to CMS, state‑specific and NCQA compliance criteria as related to Transitions of Care.
• Evaluate patient status post‑ED visit or observation stay through a clinical assessment and medical record review.
• Triage to determine appropriate follow‑up care and next steps, including reviewing medication lists and scheduling follow‑up appointments with the appropriate provider and/or specialists.
• Engage directly with inpatient physicians, case managers, medical directors, and hospitalists to facilitate safe and timely discharge, appropriate follow‑up care, and next steps.
• Coordinate with the Utilization Management team to review medical and payer records to ensure appropriate length of stay and identify any barriers to discharge.
• Assist Utilization Management team with access to external medical record information when needed to make appropriate determinations.
• Establish relationships and ensure patient/family are informed of member condition, plan of care and discharge plan, all discharge instructions, medication reconciliation, rationale of Utilization Management determinations and any financial information associated with such, potential for LTC transition (if applicable) and importance of timely PCP follow‑up following discharge.
• Conduct structured clinical assessment to identify post‑discharge needs, including medications, specialist appointments, home health, DME, caregiver support, social determinants of health, etc.
• Follow program procedures for documenting and tracking transitions interventions.
• Address identified post‑discharge needs directly or via collaboration with other team members.
• Communicate and coordinate with internal stakeholders—care team, social work, behavioral health, utilization management, Hard‑to‑Reach, Central Telehealth, etc.—to identify and address patient needs.
• Participate in regular meetings with CVS Health regional leaders, Program Director, Project Manager and other Transitional Care Managers on programmatic…