Registered Nurse (Transitions of Care)

Integrated Resources, Inc

Fort Lauderdale, FL(remote)

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JOB DETAILS

JOB TYPE

Contractor

SKILLS

Chronic Disease, Clinical Data, Clinical Medicine, Clinical Nursing, Clinical Outcomes, Clinical Support, Content Management Systems (CMS), Critical Care Registered Nurse (CCRN), Data Analysis, Diabetes, Disease Prevention and Control, Electronic Medical Records, Emergency Care, Establish Priorities, HIPAA (Health Insurance Portability and Accountability Act), Healthcare Effectiveness Data and Information Set (HEDIS), Healthcare Quality, Infection Control, Managed Care, Medical Assistance, Medical Records, Medicare, Medications, Nursing, Patient Care, Patient Confidentiality, Patient Education, Performance Management, Pharmacy, Preventive Medicine, Process Improvement, Quality Management, Reconciliation, Registered Nurse (RN), Regulations, Telehealth, Time Management, Training/Teaching, Transitional Care, Trend Analysis

LOCATION

Fort Lauderdale, FL

POSTED

5 days ago

Job Title: Registered Nurse (Transitions of Care) Location: Remote (Florida) Duration: 3+ months (possible extension) Job Summary: The Clinical Care Nurse (RN) is a clinic-based nursing role focused on improving patient outcomes, supporting safe Transitions of Care (TOC), reducing avoidable ED utilization, and driving Medicare Advantage Stars and quality performance. The Clinical Care RN plays a critical role in advancing clinical quality, supporting patients across transitions of care, improving patient outcomes, and contributing to Medicare Advantage Stars ratings by proactively identifying care opportunities, engaging patients and providers, and driving evidence-based interventions. This position balances direct patient education and outreach with data-driven quality improvement efforts. The Clinical Care RN aligns daily responsibilities with organizational values—integrity, respect, empathy, and commitment to health equity—to enhance patient health outcomes and satisfaction. Transitions: Care transition support, follow-up coordination, and avoidable readmission prevention for discharged inpatient, observation and emergency department patients Quality: Medicare Advantage Stars, HEDIS and quality performance across value-based population Population Health: Deliver culturally appropriate chronic disease education to activate patients are chronic disease self-management, particularly in Diabetes and Hypertension Duties and Responsibilities: Analyze clinical data and trends from platforms such as Athena EMR and DataHub to identify gaps in care related to HEDIS measures and Transitions of Care and post-hospitalization needs, prioritizing high-impact opportunities. Proactively identify recently discharged inpatient, observation and emergency department patients and coordinate timely post-discharge follow-up in alignment with TOC and Transitional Care Management (TCM) requirements, with the aim of addressing root causes of utilization and supporting patients to prevent avoidable readmissions or return visits. Conduct targeted patient and provider outreach via phone and telehealth visits to close care opportunities, provide tailored education on preventive care, chronic disease management, and medication management. Conduct post-discharge outreach to assess understanding of discharge instructions, bottles-out medication reconciliation, symptom monitoring, and follow-up appointment adherence. Identify and escalate barriers, collaborating with providers and care team to prevent readmissions and avoidable ED utilization Collaborate effectively with interdisciplinary teams—including providers, care assistants, center administrators, medical assistants, pharmacy, and quality improvement staff—to implement evidence-based interventions and optimize workflows. Document all outreach efforts, clinical interactions, and outcomes accurately and in compliance with organizational and CMS regulatory standards. proactively identify barriers, and contribute to developing innovative solutions to improve clinical performance and patient engagement. Maintain patient confidentiality in accordance with HIPAA Document patient encounters accurately and timely in the indicated platform (e.g., medical record) Follow organizational policies related to safety, infection control, and attendance Perform other duties as assigned Required Qualifications: Bachelor’s degree in nursing Active, unrestricted RN license (state specific as applicable). Minimum of 3 years clinical nursing experience with exposure to transitions of care, quality improvement, managed care, or population health management.

Registered Nurse (Transitions of Care)

Integrated Resources, Inc

Fort Lauderdale, FL(remote)

About the Company

Integrated Resources, Inc

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