This role supports members during transitions of care, with an emphasis on helping patients move safely between settings and close care gaps after discharge. The coach works within a care coordination model and is likely to collaborate with other clinicians to support follow-up care and resource navigation.
Key Responsibilities
- Conduct transition-of-care outreach and follow-up for members after discharge or care changes.
- Coordinate care across settings and help close gaps in treatment, referrals, and services.
- Provide education and support to members and families on post-discharge plans and next steps.
- Use clinical assessment and nursing judgment to identify needs, barriers, and escalation points.
- Document interventions, care plans, and outcomes in the appropriate care management workflow.
Required
- Active Registered Nurse (RN) license.
- Residence in Illinois.