Transitions of Care RN

Anticipated End Date: 2026-11-10 Position Title: Transitions of Care RN- Carebridge 100% Virtual- Bilingual Preferred Job Description: - Transitions of Care RN 100% Virtual, CareBridge- Bilingual Preferred CareBridge Health is a proud member of the Elevance Health family of companies, within our Carelon business. CareBridge Health exists to enable individuals in home and community-based settings to maximize their health, independence, and quality of life through home-care and community based services. Location: - Virtual: This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. - Alternate locations may be considered if candidates reside within a commuting distance from an office. - Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Work Hours: - Monday – Sunday with mandatory 2 weekends a month (4, 10 hour shifts) - Shift: 8:00AM -7:00PM (CST, MST, PST preferred time zones) Responsibilities: - The Transitions of Care RN- Carebridge is responsible for participating in delivery of patient education and disease management interventions and for performing health coaching for members, across multiple lines, for health improvement/management programs for chronic diseases. How you will make an impact: - Conducts behavioral or clinical assessments to identify individual member knowledge, skills and behavioral needs. - Identifies and/or coordinates specific health coaching plan needs to address objectives and goals identified during assessments. - Interfaces with provider and other health professionals to coordinate health coaching plan for the member. - Implements and/or coordinates coaching and/or care plans by educating members regarding clinical needs and facilitating referrals to health professionals for behavioral health needs. - Uses motivational interviewing to facilitate health behavior change. - Monitors and evaluates effectiveness of interventions and/or health coaching plans and modifies as needed. - Directs members to facilities, community agencies and appropriate provider/network. - Refers member to catastrophic case management. Minimum Qualifications: - Requires AS in nursing and minimum of 2 years of condition specific clinical or home health/discharge planning experience; or any combination of education and experience, which would provide an equivalent background