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Transition of Care Nurse

    • Job Tracking ID: 512689-606718
    • Job Location: Milwaukee, WI
    • Job Level: Mid Career (2+ years)
    • Level of Education: BA/BS
    • Job Type: Full-Time/Regular
    • Date Updated: April 20, 2018
    • Years of Experience: 2 - 5 Years
    • Starting Date: ASAP
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Job Description:

This professional position is responsible for safely and effectively transitioning iCare SNP members from acute inpatient care at an assigned hospital to home in a cost efficient manner. The Transition of Care Nurse is accountable for integrating assessment, planning, implementation, coordination, monitoring, and evaluation of services for members into a streamlined, evidence based plan of care for up to 90 days post hospital discharge. This position reports to the Manager of Specialty Services. 

Essential Duties and Responsibilities: 

  • Reviews and monitors daily inpatient stays at the assigned hospital per iCare’s inpatient work processes and participates with facility discharge planners, Care Coordinators/Care Managers and the behavioral health personnel in coordinating the member’s discharge needs.
  • Initiates Readmission Risk Assessment at time of admission, with completion and Risk determination before discharge.

a. For over 65 year old SNP members, refer member to the Readmission Prevention Program.

b. For under 65 year old SNP members, refer Low and Medium Risk members to the assigned Team RN/CC for follow-up.

c. For under 65 SNP members at High Risk for Readmission: Coordinates services, communicates information, and interfaces with inpatient and outpatient health care providers regarding the management of member’s current medical, behavioral health and social needs. Conducts home visits within 72 hours of inpatient discharge, to assure continuity of care and prevent avoidable readmissions.

  • Coordinates continuity of medical care between the hospital and primary care providers and assists members to their first follow up appointment within 21 days of discharge, depending on acuity.
  • Coordinates necessary services with ancillary providers and community agencies as appropriate to ensure member stabilization within the home including iCare’s preferred home health agencies and skilled nurse facilities.
  • Develops member-centered plan of care and assists the care manager in enforcing identified interventions during program enrollment.
  • Promotes active and ongoing engagement of members and family caregivers with a focus on goal achievement.
  • Places an emphasis on disease specific concerns as well as the early identification of and response to health care risks and symptoms to achieve long term positive outcomes while avoiding adverse events that lead to readmissions.
  • Collaborates with the multidisciplinary team across episodes of acute care and facilitates communication between and among the member, family caregivers, and health care providers.
  • Reviews and updates plan of care and expedites modifications including newly identified barriers to adherence.
  • Transitions member back to Care Coordination at program end for ongoing care coordination services.
  • Ensures that member is in compliance with standards of care as established by Federal and State initiatives.



Experience and Skills:

  • Must be a Registered Nurse, licensed in the State of Wisconsin.
  • Requires at least two years of related health care experience.
  • A personal vehicle, valid State of Wisconsin motor vehicle operator’s license and conformity with insurance coverage limits are required.
  • Ability to effectively communicate thoughts, ideas, and information both orally and in writing.
  • Ability to demonstrate flexibility, set priorities with daily demands and long-term work assignments and projects.
  • Strong interpersonal skills and ability to effectively interact with members and co-workers from a variety of different backgrounds and experiences in a professional and courteous manner.
  • Ability to work effectively as a team member and cooperate in achieving company goals.
  • Problem solving ability to seek solutions using appropriate methodologies.
  • Must be able to travel to any location within Milwaukee County.





$5,000 New Hire Bonus!


  • Independent Care Health Plan
  • 1555 RiverCenter Drive, Suite 206
  • Milwaukee, WI 53212
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