Remote License Practical Nurse TOC – Arkansas

POSITION SUMMARY

The Transition of Care Registered Nurse (TOC RN) provides clinical transition-of-care management for members enrolled in Medicare Advantage, Dual Eligible Special Needs Plans (D-SNP), Medicaid, and other managed care products. The TOC RN supports members as they transition between inpatient, observation, emergency department, post-acute, outpatient, home, and community settings.

The TOC RN conducts timely clinical assessments, identifies clinical and social risks, coordinates post-discharge services, completes medication reconciliation, facilitates follow-up care, provides member and caregiver education, and promotes safe and effective transitions. The role works collaboratively with members, caregivers, providers, hospitals, post-acute facilities, pharmacies, community organizations, Utilization Management (UM), Case Management (CM), Quality, and other Health Plan functions.

The TOC RN supports implementation of the Medicare Advantage and D-SNP Model of Care (MOC) by promoting person-centered care, coordinating services across the care continuum, participating in interdisciplinary care planning, addressing identified member needs and barriers, and ensuring appropriate transition and handoff of care. The position focuses on transition and post-discharge stabilization, with appropriate escalation and handoff to longitudinal Case Management or other clinical programs when ongoing intervention is warranted.

PRIMARY RESPONSIBILITIES

1. TRANSITION OF CARE & CLINICAL MANAGEMENT

· Identify members requiring transition-of-care intervention based on clinical risk, utilization, diagnosis, discharge disposition, and established Health Plan criteria.

· Conduct timely outreach and transition-of-care assessments following inpatient admissions, observation stays, emergency department visits, and post-acute discharges.

· Assess clinical, functional, behavioral health, medication, psychosocial, environmental, and social determinant needs.

· Identify barriers that may interfere with a safe and successful transition and develop appropriate interventions.

· Develop individualized transition-of-care plans based on the members’ clinical needs, benefits, preferences, and available resources.

· Coordinate post-discharge services, appointments, referrals, transportation, equipment, medications, and community resources.

· Monitor members following transition and modify interventions based on changes in clinical or psychosocial needs.

· Provide timely handoff to longitudinal Case Management, Complex Case Management, Disease Management, Behavioral Health, or other appropriate programs when ongoing intervention is indicated.

2. MODEL OF CARE (MOC)

· Implement applicable Model of Care requirements within transition-of-care activities for Medicare Advantage and D-SNP members.

· Support person-centered care planning that incorporates the member’s clinical, functional, behavioral health, psychosocial, cultural, and social needs.

· Participate in and contribute clinical information to the Interdisciplinary Care Team (ICT) for members requiring multidisciplinary care coordination.

· Support development, implementation, monitoring, and updating of individualized care plans (ICP) in accordance with applicable MOC requirements.

· Coordinate identified member needs and interventions across the care continuum and with appropriate internal and external providers.

· Identify and address barriers to care, including social determinants of health, access issues, transportation, medication access, caregiver needs, and coordination between Medicare and Medicaid services.

· Ensure transition-related needs identified through the MOC, health risk assessment, care plan, ICT, or other clinical processes are appropriately addressed or escalated.

· Document MOC-related assessments, interventions, coordination activities, member engagement, and outcomes in accordance with Health Plan requirements.

· Facilitate appropriate handoffs when a member’s needs require ongoing case management or additional interdisciplinary intervention.

· Support MOC performance, monitoring, audit, and quality-improvement activities as assigned.

· Maintain knowledge of applicable CMS requirements and Health Plan policies governing the D-SNP Model of Care.

3. CLINICAL COORDINATION & MEMBER ENGAGEMENT

· Provide member and caregiver education regarding diagnoses, treatment plans, medications, follow-up care, warning signs, and appropriate use of healthcare services.

· Facilitate communication among members, caregivers, PCPs, specialists, hospitals, post-acute providers, and other members of the care team.

· Perform medication reconciliation and identify discrepancies, access barriers, adherence concerns, duplications, or other medication-related risks.

· Coordinate resolution of identified medication-related concerns with providers, pharmacists, caregivers, and other appropriate clinical resources.

· Identify gaps in care and facilitate appropriate follow-up, referrals, and interventions.

4. MEDICARE ADVANTAGE & D-SNP COORDINATION

· Support the unique needs of Medicare Advantage and D-SNP members, including medically complex, high-risk, frail, disabled, and dual-eligible populations.

· Coordinate Medicare and Medicaid-covered services for applicable D-SNP members.

· Coordinate with Medicaid, LTSS, HCBS, behavioral health, and community resources when applicable.

· Support person-centered care planning and member engagement consistent with the applicable Model of Care.

· Participate in ICT activities and interdisciplinary case conferences.

· Promote continuity between acute, post-acute, primary, specialty, behavioral health, pharmacy, and community-based services.

5. COLLOBORATION WITH UM & CASE MANAGEMENT

· Collaborate with UM regarding admissions, concurrent review information, discharge planning, level-of-care concerns, and transition risks.

· Coordinate with Case Management to ensure appropriate handoff of members requiring ongoing clinical management.

· Clearly communicate outstanding clinical, medication, functional, or social needs during handoffs.

· Participate in interdisciplinary case conferences and complex case reviews as appropriate.

· Maintain clear role boundaries to prevent duplication between UM, TOC, and longitudinal CM functions.

6. DOCUMENTATION, COMPLIANCE & QUALITY

· Maintain complete, accurate, and timely documentation of assessments, outreach, interventions, care plans, referrals, education, MOC activities, and outcomes.

· Complete required activities within established Health Plan, contractual, MOC, and regulatory timeframes.

· Comply with applicable Medicare Advantage, D-SNP, Medicaid, CMS, state, HIPAA, and Health Plan requirements.

· Support MOC audits, CMS program audits, quality reviews, delegated oversight activities, and corrective action initiatives as assigned.

· Identify trends and opportunities to improve transition processes, MOC implementation, continuity of care, member experience, and clinical outcomes.

7. KEY DELIVERABLES/ MEASURES OF SUCCESS

Success in this role will be demonstrated by:

· Timely TOC Management: Complete outreach, assessments, care coordination, and follow-up within established timeframes.

· MOC & Care Planning: Implement applicable Model of Care requirements, including person-centered care plans and ICT participation.

· Clinical Coordination: Coordinate post-discharge services, medications, appointments, equipment, and community resources.

· Member Engagement: Educate and engage members and caregivers in their care and transition plans.

· Risk & Handoff: Identify and escalate clinical and social risks and appropriately transition members to Case Management or other programs.

· Documentation & Compliance: Maintain accurate documentation and comply with Medicare Advantage, D-SNP, Medicaid, CMS, MOC, and Health Plan requirements.

· Quality & Outcomes: Support improved continuity of care, member outcomes, and reduction of avoidable readmissions, ED utilization, medication issues, and gaps in care.

REQUIRED QUALIFICATIONS

· Current, unrestricted Licensed Vocational Nurse (LVN/LPN), Registered Nurse (RN) license in the applicable state(s), or LMSW

· Associate Degree in Nursing (ADN) required; BSN preferred.

· Minimum of 3 years of clinical nursing experience.

· Experience in one or more of the following: case management, care coordination, utilization management, discharge planning, population health, hospital nursing, or managed care.

· Experience working across multiple healthcare settings.

· Knowledge of clinical assessment, care planning, transition-of-care processes, medication reconciliation, and care coordination.

· Strong clinical judgment, critical thinking, communication, organization, and problem-solving skills.

· Ability to work independently and effectively within a multidisciplinary team.

· Proficiency with electronic medical records and care management systems.

PREFERRED QUALIFICATIONS

· Bachelor of Science in Nursing (BSN).

· Certified Case Manager (CCM), Accredited Case Manager (ACM), or other relevant clinical certification.

· Experience with Medicare Advantage, D-SNP, Medicaid, or other managed care products.

· Experience implementing or supporting a CMS-approved Model of Care.

· Experience with D-SNP care coordination, individualized care plans, and Interdisciplinary Care Teams.

· Experience with dual-eligible, medically complex, high-risk, frail, or vulnerable populations.

· Experience coordinating LTSS, HCBS, behavioral health, or community-based services.

· Knowledge of CMS Medicare Advantage, D-SNP, and Model of Care requirements.

· Experience with readmission reduction, population health, quality improvement, or value-based care initiatives.

· Experience with care management platforms and population health technologies.

Pay: $49,920.00 – $62,400.00 per year

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Work Location: Remote