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Readmission Prevention Nurse Practitioner

    • Job Tracking ID: 512689-624041
    • Job Location: Milwaukee, WI
    • Job Level: Mid Career (2+ years)
    • Level of Education: Masters Degree
    • Job Type: Full-Time/Regular
    • Date Updated: June 08, 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 members from acute inpatient care to home in a cost efficient manner. The Transition of Care Coach is accountable for integrating assessment, planning, implementation, coordination, monitoring, and evaluation of services for members into a streamlined, evidence based plan of care during the 30 day period post hospital discharge.

  1. Conducts home visits within 72 hours of inpatient discharge, to assure continuity of care and prevent avoidable readmissions.
  2. Coordinates continuity of medical care between the hospital and primary care providers and assists members to their first follow up appointment within 7 days of discharge.
  3. Coordinates necessary services with ancillary providers and community agencies as appropriate to ensure member stabilization within the home.
  4. Develops member centered plan of care and assists the care manager in enforcing identified interventions during the 30 day period post discharge
  5. Promotes active and ongoing engagement of members and family caregivers with a focus on goal achievement.
  6. 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.
  7. Collaborates with the multidisciplinary team across episodes of acute care and facilitates communication between and among the member, family caregivers, and health care providers.
  8. Reviews and updates plan of care and expedites modifications including newly identified barriers to adherence
  9. Maintains active caseload
  10. Ensures that member is in compliance with standards of care as established by Federal and State initiatives

Experience and Skills:

  1. Must be a Nurse Practitioner, licensed in the State of Wisconsin.
  2. Requires at least two years of related health care experience.
  3. A personal vehicle, valid State of Wisconsin motor vehicle operator’s license and conformity with insurance coverage limits are required.
  4. Ability to effectively communicate thoughts, ideas, and information both orally and in writing.
  5. Ability to demonstrate flexibility, set priorities with daily demands and long-term work assignments and projects.
  6. 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.
  7. Ability to work effectively as a team member and cooperate in achieving company goals.
  8. Problem solving ability to seek solutions using appropriate methodologies.
  9. Must be able to travel to any location within MilwaukeeCounty.
  10. Ability to use a personal computer and capability of learning software applications of Independent Care.
  11. Ability to work independently with minimal supervision.
  12. Case Management skills to determine appropriateness of member’s care.


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