Transition of Care, Licensed Practical Nurse

Job Summary The Transition of Care Coach is responsible for care coordination of our members who are experiencing a significant change in health status which has resulted in the necessity of an emergency department visit, inpatient, skilled nursing, or rehabilitative stay. Under the direction of a Registered/Licensed RN, the TOC Coach ensures the member experiences a seamless transition to their next care setting and facilitates post-discharge goal attainment by:

• Complete post-discharge questionnaire, which may be market specific.
• Ensures the member has filled/received their medication(s) and has an understanding on how to take their ordered medications.
• Benefit education
• Monitor members in low CM level for alerts or changes in condition to be transitioned back to RN.
• Complete post discharge call and required assessments (RAP), medication reconciliation (if within scope of practice), fall assessment if fall risk identified.
• Complete inpatient confinement calls and monitoring for discharge
• Management of warm transfers form concierge and engagement hub

- Provides clinical assistance to determine appropriate services and supports due to member’s health needs (including but not limited to: Coordination with -PCP and Specialty providers, Condition Management information and education, Medication management, Community Resources and supports)

• Evaluation of health and social indicators
• Identifies and engages barriers to achieving optimal member health.
• Uses discretion to apply strategies to reduce member risk.
• Facilitates 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.
• Coordinates post-discharge meal delivery, assists with securing DME, and helps to ensure timely physician follow-up.
• Understands Payer/Plan benefits, policies, procedures, and can articulate them effectively to providers, members, and other key personnel.

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. Focus 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. Additional responsibilities to include but not limited to the following:

• Responsible for completing outreach cadence calls and post-discharge questionnaires within required compliance driven timelines.
• 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.

REQUIRED QUALIFICATIONS

• 2 years work experience
• Licensed Practical Nurse (LPN)
• Discharge planning
• Advanced proficiency in Microsoft Word, Excel, and Outlook

PREFERRED QUALIFICATIONS

• Self-motivated, energetic, detail-oriented, highly organized, tech-savvy Licensed Practical Nurses
• Ability to multitask, prioritize, and effectively adapt to a fast-paced changing environment while providing outstanding care.
• Effective verbal and written communication skills
• Bilingual a plus (English/ Spanish)
• Home Health experience
• Associate's Degree and/or Bachelor's Degree

EDUCATION High School Diploma or equivalent GED plus Licensed Practical Nurse Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $21.10 - $43.78 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 07/25/2025 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. Apply Job! Apply to this Job