Transition of Care Registered Nurse - IL Licensed RN

Why Join Grace at Home?

Grace at Home is a provider-led, community-based health and care partner dedicated to improving the health and well-being of those who need care the most, with a deep commitment to high-needs, urban and rural communities. Our local physicians, nurses, and caregivers work together to serve people and the communities they live in, beyond just treating symptoms. We remove barriers by delivering personalized care as close to home as possible, often in-home, because we know a deep understanding of our patient’s race, culture, and environment is critical to delivering improved health outcomes. By empowering patients, providers, and caregivers with the support they need, we strive to make health and care a reality—not a burden—every single day. Join us in creating a better way to care.

Overview

The Transitions of Care (TOC) Nurse provides timely, telephonic clinical outreach to family members following acute care, skilled nursing, or facility-based discharges to support safe and effective transitions across care settings. This role focuses on reducing avoidable readmissions, closing quality care gaps, and improving patient outcomes through assessment, education, care coordination, and escalation as needed. The TOC Nurse serves as a critical clinical touchpoint during high-risk transition periods and collaborates closely with interdisciplinary teams to ensure continuity of care. This role supports value-based care objectives by improving utilization outcomes and quality performance.

Duties & Responsibilities

• Transitions of Care Outreach & Clinical Support
  • Conduct timely post-discharge telephonic outreach in accordance with established TOC workflows and timelines.
  • Perform comprehensive clinical assessments to identify post-discharge risks, unmet needs, and barriers to recovery.
  • Complete medication reconciliation, reinforce discharge instructions, and assess understanding of care plans.
  • Educate family members on symptom monitoring, red flags, follow-up care, and self-management strategies.
  • Coordinate follow-up appointments with primary care providers, specialists, and ancillary services as appropriate.

• Utilization Management

  • Monitor emergency department, skilled nursing facility, and hospital admission feeds to identify transitions of care opportunities and initiate timely outreach.
  • Support effective transitions of care through coordination with hospitals, SNFs, caregivers, and care teams.
  • Track care plan interventions and outcomes and reassess Family Member needs on an ongoing basis.
  • Identify long length of stay admissions in hospital, LTAC, and SNF and escalate to clinical team as needed.

• Care Coordination & Escalation

  • Identify and escalate clinical concerns, care gaps, or social barriers to appropriate care team members.
  • Collaborate with primary care practices, care managers, pharmacists, social workers, and other partners to ensure continuity of care.
  • Facilitate referrals to community-based resources or internal programs to address identified needs.
  • Document and communicate actionable information to support timely intervention and risk mitigation.

• Quality & Value-Based Care Support

  • Support closure of quality gaps related to transitions of care, medication adherence, and follow-up.
  • Contribute to reduction of hospital readmissions, emergency department utilization, and total cost of care.
  • Adhere to evidence-based TOC models and organizational protocols aligned with value-based care programs, including ACO and MSSP requirements.
  • Participate in quality improvement initiatives and feedback loops to enhance TOC effectiveness.

• Documentation & Reporting

  • Accurately document all outreach, assessments, interventions, and outcomes in designated EHRs or care management platforms.
  • Ensure timely, complete, and compliant documentation to support reporting, audits, and performance monitoring.
  • Communicate key findings and trends to leadership and interdisciplinary teams as required.

• Professional Practice

  • Maintain active RN licensure and adhere to professional nursing standards and scope of practice.
  • Participate in onboarding, training, and ongoing education related to transitions of care and value-based care models.
  • Support a culture of patient-centered, high-quality, and accountable care delivery.

Qualifications

• Licensure: Active Registered Nurse (RN) license in good standing required in IL; ability and willingness to obtain multi-state licensure.

  Education: Bachelor of Science in Nursing (BSN) required.

  Experience:

  • Clinical nursing experience required; experience in care management, transitions of care, case management, or population health preferred.
  • Experience providing telephonic or remote patient support preferred.
  • Familiarity with post-acute care settings, discharge planning, or care coordination strongly preferred.

• Skills:

  • Strong clinical assessment and critical thinking skills.
  • Excellent communication and patient education abilities.
  • Ability to manage multiple patients and priorities in a remote environment.
  • Proficiency with EHRs, care management systems, and documentation tools.
  • Comfort working independently while collaborating with interdisciplinary teams.

The working environment and physical requirements of the job include:

Work is performed indoors in a setting with air conditioning and artificial light. Travel to and work in offices or other environments is required. 

In this position you will need to communicate with customers, vendors, management, and other co-workers in person and over devices, sometimes with people who are agitated. Regular use of the telephone and e-mail for communication is essential. Sitting for extended periods is common. Must be able to receive ordinary information and to prepare or inspect documents. Lifting of up to 10 lbs. occasionally may be required. Good manual dexterity for the use of common office equipment such as computer terminals, calculator, copiers, and FAX machines. Good reasoning ability is important. Able to understand and utilize management reports, memos, and other documents to conduct business.

Equal Opportunity & Reasonable Accommodation Statement

Grace at Home is an Equal Opportunity Employer committed to creating an inclusive environment for all employees. We provide equal employment opportunities to all individuals regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other protected characteristic under applicable law.

If you require reasonable accommodation during the application or employment process, please inform the recruiter during the hiring process.

Disclaimer

This job description is intended to describe the general nature and level of work being performed. It is not intended to be an exhaustive list of all responsibilities, duties, and skills required. Management reserves the right to modify, add, or remove duties as necessary.

Our Benefits

Financial Well-being

• Competitive Compensation: We offer competitive salaries to attract and retain the best talent.
• 401(k) with Employer Match: Plan for your future with our 401(k) plan and a generous 4% employer match.

Health and Wellness

• Comprehensive Medical Plan: We proudly offer a comprehensive medical option with an employer contribution.
• Dental & Vision Coverage: Maintain your oral and eye health with our employer-paid dental and vision plans via MetLife.
• Employer-Paid Insurance: Life, Short-Term Disability (STD), and Long-Term Disability (LTD) insurance are provided at no cost to you.
• Generous Paid Time Off: Enjoy ample time off for rest and rejuvenation with generous PTO, holidays, and wellness time.

Additional Perks

• Continuing Medical Education (CME) Allowance for APPs: Stay at the forefront of your field with our CME allowance.
• Commuter Benefits: Save on your commute with our commuter benefits program.
• Mileage Reimbursement: Get reimbursed for work-related travel expenses.