**Transitions of Care-Nurse Registered** 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. **Shift:** 4x 10hr shifts Monday-Sunday including 1 weekend (Saturday and Sunday) a month. Rotating holidays are also required or 4 x 10hr shifts Monday-Sunday including EVERY weekend (Saturday and Sunday) a month. 1 Rotating holidays are also required **This position is primarily a Virtual/Remote role.** The Transitions of Care-Nurse Registered will be 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 post admission assessments including 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 + Uses motivational interviewing to facilitate health behavior change + Monitors and evaluates effectiveness of interventions and/or health coaching plans and modifies as needed + Provide compassionate care to diverse patients and their families. + Educate and triage the care of individuals experiencing an acute transition of care with a multitude of health problems ranging from primary care to urgent care issues + Perform follow up and check in with patients to monitor post-discharge course. + Active participation in quality improvement processes and initiatives + Reviews and reconciles medications + Escalates complex cases to the interdisciplinary team as needed to get the best outcomes for the patient + Recognizes and responds promptly and appropriately to emergency situations + Provides effective patient education using the Teach-Back technique + Documents all patient encounters per documentation standards + Maintains excellent punctuality and attendance during work hours **Minimum Requirements:** + 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 **Preferred Skills, Capabilities, and Experiences:** + Current unrestricted Compact RN license in applicable state(s) strongly preferred + **Bilingual in English and Arabic is strongly preferred** + Experience in care of adult, chronically ill patients, chronically ill pediatric patients, and patients with IDD + Home Health, Utilization Management or Case Management experience strongly preferred + Previous Transitions of Care experience a plus + Working knowledge of computers and ability to document effectively and efficiently in an electronic system + Expert communicator over the telephone, providing timely, appropriate advice and/or guidance with health care issues + Hx of care of members with multiple chronic medical conditions such as COPD, CHF, CKD, Catheters, Wounds, Psych + Dependability—We work with a buddy system/team system. It is very important to work during your scheduled shifts Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws. Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.