Transition of Care Associate LPN

Transition of Care Associate LPN

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

Help us elevate our member care to a whole new level! Join our Aetna team as an industry leader in serving dual eligible populations by utilizing best-in-class operating and clinical models. You can have life-changing impact on our Dual Eligible Special needs Plan (D-SNP) members, who are enrolled in Medicare and Medicaid and present with a wide range of complex health and social challenges. With compassionate attention and excellent communication, we collaborate with members, providers, and community organizations to address the full continuum of our members' health care and social determinant needs. Join us in this exciting opportunity as we grow and expand D-SNP to change lives in new markets across the country.

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:

• Completing post-discharge questionnaires, which may be market specific.
• Providing comprehensive discharge planning.
• Ensuring the member has filled/received their medication(s) and has an understanding of how to take their ordered medications.
• Benefit education.
• Providing 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.
• Identifying and engaging barriers to achieving optimal member health.
• Using discretion to apply strategies to reduce member risk.
• Presenting cases at case conferences for multidisciplinary focus to benefit overall member management.
• Facilitating 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.
• Coordinating post-discharge meal delivery, assisting with securing DME, and helping to ensure timely physician follow-up.
• Understanding Payer/Plan benefits, policies, procedures, and articulating them effectively to providers, members, and other key personnel.
• Updating the Care Plan for any change in condition or behavioral health status.

Our TOC Coaches are frontline advocates for members who cannot advocate for themselves. The TOC team will review prior claims to address potential impact on current case management and eligibility status. Assessments and/or questionnaires are designed to use a holistic approach to identify the need for a referral to clinical resources for assistance in functionality.

Responsibilities

• Responsible for completing outreach cadence calls and post-discharge questionnaires within required compliance-driven timelines.
• Utilizing weekly and daily reporting to identify utilization for the purpose of reducing Emergency Department Utilization and 30-day hospital readmissions.
• Following members identified as inpatient in hospitals (whether planned or unplanned admission) and then throughout the subsequent care continuum until member can return to prior level of functioning in the community.
• Facilitating Interdisciplinary Care Team Meetings with Social Services, Care Management, PCP and other key players to discuss service needs and support safe transitions.

Required Qualifications

• Candidate must be a Licensed Practical Nurse (LPN).
• 2+ years experience as a Licensed Practical Nurse (LPN).
• Self-motivated, energetic, detail-oriented, highly organized, tech-savvy Licensed Practical Nurses.
• Basic proficiency in Microsoft Word, Excel, and Outlook.
• Ability to multitask, prioritize, and effectively adapt to a fast-paced changing environment while providing outstanding care.
• Effective verbal and written communication skills.

Preferred Qualifications

• Discharge planning.
• Bilingual.

Education

• High School Diploma or equivalent experience (REQUIRED).
• Associate's Degree (PREFERRED).
• Bachelor's Degree (PREFERRED).

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The Typical Pay Range For This Role Is: $24.64 - $53.53

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great Benefits For Great People

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

Additional details about available benefits are provided during the application process and on Benefits Moments.

We anticipate the application window for this opening will close on: 05/31/2026

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Key skills/competency

• Licensed Practical Nurse (LPN)
• Care Coordination
• Discharge Planning
• Patient Advocacy
• Medication Management
• Community Resources
• Health Care Operations
• Patient Education
• Case Management
• Interdisciplinary Communication