We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Help us elevate our member care to a whole new level! Join our Aetna Team as an industry leader in serving dual eligible populations by utilizing best-in-class operating and clinical models. You can have life-changing impact on our Dual Eligible Special Needs Plan (D-SNP) members, who are enrolled in Medicare and Medicaid and present with a wide range of complex health and social challenges. With compassionate attention and excellent communication, we collaborate with members, providers, and community organizations to address the full continuum of our members' health care and social determinant needs. Join us in this exciting opportunity as we grow and expand D-SNP to change lives in new markets across the country. 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. 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. • Providing comprehensive discharge planning • Ensures the member has filled/received their medication(s) and has an understanding on how to take their ordered medications. • Benefit education • Provides clinical assistance to determine appropriate services and supports due to member’s health needs (including but not limited to Prior Authorizations, 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. • Presents cases at case conferences for multidisciplinary focus to benefit overall member management. • 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. • Updates the Care Plan for any change in condition or behavioral health status. 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. 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. RESPONSIBILITIES 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. EDUCATION Required H.S. or Equivalent - MUST be an LPN Preferred Associate's Degree, Bachelor's Degree PRIOR WORK EXPERIENCE Required 2+ years LPN nursing experience Preferred 3+ years LPN nursing experience REQUIRED SKILLS & OTHER MINIMUM REQUIRED QUALIFICATIONS • Self-motivated, energetic, detail-oriented, highly organized, tech-savvy Licensed Practical Nurses • Discharge planning • Advanced proficiency in Microsoft Word, Excel, and Outlook • 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! Anticipa Apply To This Job