Transitional Care Navigator Job at Arcadia Home Care and Staffing

Rn - Transitional Care Navigator

Harrison's Hope Hospice is seeking an RN Transitional Care Navigator. This posit...

Location

United States , Meridian

Salary:

Not provided

Arcadia Home Care and Staffing - an Addus family company

Expiration Date

Until further notice

Requirements

Bachelor’s degree in marketing, business administration, or other related fields is preferred
Licensed as a registered nurse in the state of practice, a plus
Must possess the ability to make independent decisions when circumstances warrant
Must possess the ability to deal tactfully with patients, family members, visitors, agency personnel, and general public
Must be knowledgeable of quality assessment and assurance procedures
Valid driver’s license and proof of insurance is required

Job Responsibility

Collaboration with the Hospice Liaison team and Admissions team to increase public awareness of hospice and other services provided by the agency and to drive admissions for the placement of patients to meet expectations
Act as first point of contact for hospitals, health care facilities, and other sources regarding referrals
Seek networking opportunities to provide education and to develop relationships with new and existing referral sources
Identifying appropriate care and services to patient and family in accordance with attending physician and plan of care, as well as company policy and procedures

What we offer

Great culture and team atmosphere
Comprehensive benefits (medical, dental, vision, life/AD&D, disability), effective on the first of the month
401(k) retirement plan with a generous company match
Generous time off accruals
Paid holidays
Mileage reimbursement
Tuition Reimbursement
Employee Referral Program
Merit Increases
Employee Discount Programs

Transitional Care Navigator

Addus Home Care / JourneyCare Hospice is seeking a Hospice Transitional Care Nav...

Location

United States , Naperville

Salary:

82000.00 - 93000.00 USD / Year

Arcadia Home Care and Staffing - an Addus family company

Expiration Date

Until further notice

Requirements

Bachelor’s degree in marketing, business administration, or other related fields is preferred
Licensed as a registered nurse in the state of practice, preferred
Minimum of two years relevant experience
Must possess the ability to make independent decisions when circumstances warrant
Must possess the ability to deal tactfully with patients, family members, visitors, agency personnel, and public
Must be knowledgeable of quality assessment and assurance procedures
Valid driver’s license and proof of insurance is required

Job Responsibility

Serve as hospice clinical consultant and educator, acting as extensions of hospital and physician care team
Review hospital clinical documentation/EMR/HCHB, engage with patients and providers to build clinical patient profiles and clinical-admission-assessments and identify decline patterns
Consult with hospital care teams by sharing clinical profiles and educating on hospice appropriateness
Identify attending and consulting providers associated with referred patients – to provide patient assessment, eligibility and discharge education and awareness
Collaborate with field sales representatives to schedule and conduct consultative meetings with external care teams
Initiate and maintain care team workflows for: Patient information / clinical assessment and documentation, Consultation / education planning and delivery, External and internal meetings and preparations
Identify trends, needs, and partnership opportunities for earlier hospice engagement
Foster effective and trusted relationships with external care teams to improve patient outcomes and enhance end-of-life satisfaction
Communicate clearly and consistently with hospital leadership and care coordination teams
Effectively organize, track and prioritize high-value patient comprehensive reviews

What we offer

Great culture and team atmosphere
Comprehensive benefits (medical, dental, vision, life/AD&D, disability), effective on the first of the month
401(k) retirement plan with a generous company match
Generous time off accruals
Paid holidays
Mileage reimbursement
Tuition Reimbursement
Employee Referral Program
Merit Increases
Employee Discount Programs

Fulltime

Nurse Practitioner, Transitional Care

The Advanced Practice Provider, Transitions delivers high-touch, high-quality ca...

Location

United States , Indianapolis

Salary:

Not provided

CVS Health

Expiration Date

July 21, 2026

Requirements

Have an active, non-probationary state medical license, including US work authorization, if applicable
1+ years APN experience, preferably with a Medicare population
Experience in home-based care (as RN or APP) preferred
Flexibility to travel throughout service area
Electronic Medical Record experience
Computer skills: Ability to quickly navigate and use multiple computer programs to include, but not limited to: Gmail, MS Word or Google Docs, Excel or Google Sheets, etc.
Additional language proficiency in Spanish, Polish, Russian, or other languages spoken within the communities we serve preferred but not required

Job Responsibility

Provide post-discharge support according to defined pathways within the patient's home
Develop care plans and individualize goals of care with patient, their families, and their providers
Optimize and monitor clinical status, identify and address gaps in care, reconcile medications and address adherence challenges
Collaborate with Transitional Care Managers, home health, social workers, hospitals, SNFs, and specialists
Structure and prioritize scheduling based on clinical complexity for both new and routine patients
Recognize, diagnose, and manage both acute and chronic medical conditions in order to prevent destabilization and readmissions
Provide after-hours and weekend call support, shared with other in-state providers
Facilitate and conduct goals of care and advance care planning discussions with patients and families
Assess and evaluate family/caregiver needs and limitations
Teach patients, caregivers, and others about their health conditions

What we offer

Mission-focused career impacting change and measurably improving health outcomes for Medicare patients
Paid vacation, sick time, and investment/retirement 401K match options
Health insurance, vision, and dental benefits
Opportunities for leadership development and continuing education stipends
New centers and flexible work environments
Opportunities for high levels of responsibility and rapid advancement
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
Paid time off
Flexible work schedules

Fulltime

Transitional Care Advanced Practice Provider (APP)

The Advanced Practice Provider, Transitions delivers high-touch, high-quality ca...

Location

United States , St. Louis, MO

Salary:

78000.00 - 168714.00 USD / Year

CVS Health

Expiration Date

March 16, 2026

Requirements

Have an active, non-probationary state medical license, including US work authorization, if applicable
1+ years APN experience, preferably with a Medicare population
Experience in home-based care (as RN or APP) preferred
Flexibility to travel throughout service area
Electronic Medical Record experience
Computer skills: Ability to quickly navigate and use multiple computer programs to include, but not limited to: Gmail, MS Word or Google Docs, Excel or Google Sheets, etc.
Additional language proficiency in Spanish, Polish, Russian, or other languages spoken within the communities we serve preferred but not required

Job Responsibility

Provide post-discharge support according to defined pathways within the patient's home
Develop care plans and individualize goals of care with patient, their families, and their providers
Optimize and monitor clinical status, identify and address gaps in care, reconcile medications and address adherence challenges
Collaborate with Transitional Care Managers, home health, social workers, hospitals, SNFs, and specialists
Structure and prioritize scheduling based on clinical complexity for both new and routine patients
Recognize, diagnose, and manage both acute and chronic medical conditions in order to prevent destabilization and readmissions
Provide after-hours and weekend call support, shared with other in state providers
Facilitate and conduct goals of care and advance care planning discussions with patients and families
Assess and evaluate family / caregiver needs and limitations
Teach patients, caregivers, and others about their health conditions

What we offer

Mission-focused career impacting change and measurably improving health outcomes for Medicare patients
Paid vacation, sick time, and investment/retirement 401K match options
Health insurance, vision, and dental benefits
Opportunities for leadership development and continuing education stipends
New centers and flexible work environments
Opportunities for high levels of responsibility and rapid advancement

Fulltime

Transitional Care Advanced Practice Provider

The Advanced Practice Provider, Transitions delivers high-touch, high-quality ca...

Location

United States , Rockford

Salary:

87035.00 - 206206.00 USD / Year

CVS Health

Expiration Date

May 16, 2026

Requirements

Genuine passion for reaching vulnerable patients
strong clinical skills focused on older adults with complex disease states
comfort navigating visits in patient homes
demonstrated ability to collaborate effectively in a team setting
willingness to learn and be accountable for visit documentation and workflows
excellent communication, follow-up, teamwork, and problem-solving skills
desire to be a part of a fast-paced, innovative, quality-driven organization
have an active, non-probationary state medical license, including US work authorization
1+ years APN experience, preferably with a Medicare population
experience in home-based care (as RN or APP) preferred

Job Responsibility

Provide post-discharge support according to defined pathways within the patient's home
develop care plans and individualize goals of care with patient, their families, and their providers
optimize and monitor clinical status, identify and address gaps in care, reconcile medications and address adherence challenges
collaborate with transitional care managers, home health, social workers, hospitals, SNFs, and specialists
structure and prioritize scheduling based on clinical complexity for both new and routine patients
recognize, diagnose, and manage both acute and chronic medical conditions in order to prevent destabilization and readmissions
provide after-hours and weekend call support, shared with other in-state providers
facilitate and conduct goals of care and advance care planning discussions with patients and families
assess and evaluate family/caregiver needs and limitations
teach patients, caregivers, and others about their health conditions

What we offer

Mission-focused career impacting change and measurably improving health outcomes for Medicare patients
paid vacation, sick time, and investment/retirement 401K match options
health insurance, vision, and dental benefits
opportunities for leadership development and continuing education stipends
new centers and flexible work environments
opportunities for high levels of responsibility and rapid advancement
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 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

Fulltime

Transitional Care Services Community Health Worker II

The Transitional Care Services (TCS) Community Health Worker II (CHW) is respons...

Location

United States , Los Angeles

Salary:

55245.00 - 82867.00 USD / Year

L.A. Care Health Plan

Expiration Date

Until further notice

Requirements

High School Diploma/or High School Equivalency Certificate
At least 6 months of experience as a health navigator, peer support worker, outreach worker, promotora, or working in a community setting and providing health education for chronic conditions, or equivalent
Knowledge of community resources for Medi-Cal members
Comfortable working with diverse populations
Exceptional ability to connect and engage with people
Willingness to work in various environments including 1:1 in member’s homes, hospitals, skilled nursing facilities, other clinical settings, and/ or shelters
Excellent verbal and written communication skills
Detail oriented, organized and possess time management skills
Basic computer skills
Must have access to reliable transportation to carry out job-related essential functions

Job Responsibility

Cultural Mediation Among Individuals, Communities, and Health and Social Service Systems: Educating individuals and communities about how to use health and social service systems (including understanding how systems operate). Educating systems about community perspectives and cultural norms. Building health literacy and cross-cultural communication
Providing Culturally Appropriate Health Education and Information: Conducting health promotion and disease prevention education in a manner that matches linguistic and cultural needs of members. Providing necessary information to understand and prevent diseases and help members manage health conditions (including chronic disease)
Care Coordination, Case Management, and System Navigation: Participating in telephonic and/or in-person care coordination and case management with members, facility staff, and providers. Making post-transition referrals and providing follow-up. Coordinating transportation to services and helping address barriers to services. Documenting and tracking individual and population level data. Informing people and systems about community assets and challenges
Providing Coaching and Social Support: Providing individual support and coaching, including how to manage their health conditions following discharge and identifying critical symptoms. Motivating and encouraging people to obtain care and other services. Supporting self-management of disease prevention and management of health conditions (including chronic disease). Planning and/or leading support and health education groups
Advocating for Individuals and Communities: Advocating for the needs and perspectives of communities. Connecting to resources and advocating for basic needs (e.g. food and housing). Conducting policy advocacy for their communities
Building Individual and Community Capacity: Building individual and community capacity by training with peers and among CHW groups
Implementing Individual Assessments: Participating in design, implementation, and interpretation of individual-level assessments (e.g. Health Risk Assessments, medication reviews, home environmental and safety assessment)
Conducting Outreach: Telephonic and/or in-person recruitment of individuals and families to participate in Transitional Care Services and other supports. Follow up on health and social service encounters with individuals and families, in coordination with primary care providers and facility staff. Home visiting to provide education, assessment, and social support following a care transition, if appropriate
Perform other duties as assigned

What we offer

Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)

Fulltime

New

Hospice Clinical Liaison

JourneyCare Hospice is seeking a Hospice Clinical Liaison to join our growing te...

Location

United States , Chicago

Salary:

75000.00 - 92000.00 USD / Year

Arcadia Home Care and Staffing - an Addus family company

Expiration Date

Until further notice

Requirements

Graduate from an accredited registered nursing program
Licensed as a registered nurse in the state of practice
Must possess current CPR, First Aid Certification
1 year experience, preferred
Willingness to travel 50% or more in assigned territory
Must possess the ability to make independent decisions when circumstances warrant
Must possess the ability to deal tactfully with patients, family members, visitors, agency personnel, and general public
Must be knowledgeable of quality assessment and assurance procedures
Valid driver’s license and proof of insurance is required

Job Responsibility

Respond promptly to hospice referrals and perform real-time, bedside clinical assessments
Support the admission process by assisting with initial patient intake, including explaining hospice services and benefits to patients and families in both home and clinical settings
Gather comprehensive data on physical, psychological, social, and spiritual factors that may impact the patient’s and family’s needs and coordinate appropriate interventions with the interdisciplinary team
Conduct clinical assessments and gather information to support physician determination of hospice eligibility
Build and maintain client relationships
Responds to customer needs and concerns in a timely manner
Completes required admission documentation, including consents and CTI (Certification of Terminal Illness) coordination
Facilitate and activate the admission workflow for eligible patients in collaboration with the hospice team
Coordinate and support General Inpatient (GIP) admissions in partnership with the hospice centers
Serve as an on-site clinical presence for immediate admissions or as a resource to field RNs, as needed

What we offer

Great culture and team atmosphere
Comprehensive benefits (medical, dental, vision, life/AD&D, disability) effective on the first of the month following start date
401(k) retirement plan with a generous company match
Generous time off accruals
Paid holidays
Mileage reimbursement
Tuition Reimbursement
Employee Referral Program
Merit Increases
Employee Discount Programs

Fulltime

Director, System Care Coordination

Aspirus Health is seeking an experienced and strategic leader to oversee system-...

Location

United States , Wausau

Salary:

Not provided

Kirby Bates Associates

Expiration Date

Until further notice

Requirements

Bachelor’s in nursing and Master’s in business, healthcare administration, or nursing required
Nationally recognized certification preferred, i.e. CPHQ, CCM, CPUM, CPUR, or D-ABQAURP
Five or more years of leadership experience in care coordination, case management, or utilization review in an integrated healthcare delivery system and/or health plan
Extensive knowledge of payer mechanisms, clinical utilization management, outcome measures and patient information systems in including Pathways, HEDIS, etc.

Job Responsibility

Oversee system-wide care coordination functions, including utilization review, social work, navigation, and case management
Execute Aspirus’ care coordination strategic plan
Ensure seamless transitions of care
Drive initiatives that enhance health system and health plan goals
Lead the development and implementation of best practices, policies, and procedures across the continuum of care
Supervise a multidisciplinary team of registered nurses, social workers, and other healthcare professionals
Collaborate with business units to optimize resource utilization, improve patient outcomes, and achieve strategic objectives
Accountable for financial stewardship, program development, and regulatory compliance.

What we offer

Robust opportunities for leadership growth
Career advancement
Chance to shape the future of care coordination across an expansive health system.

Transitional Care Navigator

Arcadia Home Care and Staffing - an Addus family company

Location:
United States , Chicago

Category:
Nursing

Contract Type:
Not provided

Salary:

Job Description:

Job Responsibility:

Requirements:

Additional Information:

Job Posted:
December 20, 2025

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