Transition of Care Associate – Licensed Practical Nurse

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. Position Summary 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. ...