RN Full-time
CVS Health

Transition of Care Registered Nurse - Field in Central NJ

CVS Health Flemington, NJ 08822, US
$32.01 - $68.55 / hour
Apply Now

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:

This role plays a vital part in helping members successfully transition from nursing facilities back into the community. The position focuses on managing incoming referrals for nursing facility transitions, maintaining a strong on‑site presence, and coordinating safe, timely discharges that promote independence and quality of life.

The individual will be embedded in assigned nursing facilities 2–3 days or more per week, based on member needs and acuity, building trusted relationships with facility staff and interdisciplinary teams. Responsibilities include assessing member readiness to return home, facilitating Interdisciplinary Team (IDT) meetings, and developing comprehensive, member‑centered transition plans of care.

Rather than carrying a traditional caseload, this role is outcome‑focused, with a monthly goal of successfully transitioning three members from nursing facilities back to the community. The position also requires community follow‑up, meeting members face‑to‑face after discharge to complete a NJ Choice Change in Condition assessment within 10 business days of discharge.

In addition, the role participates in workgroup meetings, contributing insights that help improve processes, outcomes, and overall transition success. This position is ideal for someone who thrives in a collaborative environment, values meaningful in‑person engagement, and is passionate about helping members return home safely and confidently.

Additional Job Details:

  • Candidate must utilize workflows, processes, and critical thinking to ensure member remains in community for 6 months post transition
  • Actively engage in preventive care efforts by scheduling and confirming member appointments, coordinating transportation, and promoting adherence to care plans.
  • Implement strategies to reduce avoidable emergency department visits and hospital admissions through early intervention and education.
  • Provide enhanced member education on in-home safety measures, including fall prevention and medication adherence.
  • When appropriate, accompany members to medical appointments to support care continuity and ensure understanding of treatment plans.
  • Applies critical thinking, evidence-based clinical criteria to support contractual rebalancing goals:
  • Support the Health Plan Rebalancing Initiative goal of successful transitions: Identify and assess members to transition from the Nursing Facility (NF) setting into the community
  • Follow up on CM referrals and visit current NF members in-person twice a week as needed to complete the rebalancing events and assessments.
  • Complete telephonic or in-person contact as appropriate to assess the home prior to discharge and identify any environmental supports needed to support transition (i.e. ramp, DME installation etc.).Conduct an in-person Significant Change Visit with member and Rep if applicable, within 7 business days of transition. Coordinate provision of services as needed, establish Plan of Care, and document all actions taken.
  • Contact facility’s Business Office once a week to follow-up on member's census and coordinate with Social Services and CM to facilitate discharge.
  • Work collaboratively with health plan case managers to identify high risk community members and implement appropriate interventions to prevent lapse or coordinate safe transition (Upon receiving referral)
  • Drive enhanced value of health care to increase member satisfaction and retention, and drive new membership growth.
  • Engage in building strong relationships that contribute towards member satisfaction and retention

Required qualifications:

  • Active, unrestricted and good standing RN license in the state of New Jersey
  • Minimum 2 years of clinical experience
  • Experience in all or some of the following: Managed Care, Discharge coordination, Transition of care, Home Health, Case Management and Medicaid
  • Must possess reliable transportation and be willing and able to travel up to 75% of the time in the assigned coverage area of New Jersey. Mileage is reimbursed per our company expense reimbursement policy
  • Must reside in Central New Jersey; Hunterdon, Middlesex, Mercer, Somerset and Monmouth Counties

Preferred qualifications:

  • 2 or more years clinical nursing experience in home health, case management and/or discharge planning.
  • Position requires proficiency with computer skills which includes navigating multiple systems
  • Ability to work in a fast-paced environment

Education:

Associate Degree Required

BSN preferred.

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$32.01 - $68.55

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: 04/30/2026

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

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Please Note: We will only contact candidates regarding your applications from one of the following domains: @summithealth.com, @citymd.net, @villagemd.com, @villagemedical.com, @westmedgroup.com, @starlingphysicians.com, or @bmctotalcare.com. Job Description Essential Job functions : Provides total comprehensive care to patients by applying the nursing process in an organized and systematic manner according to the Center’s policy in keeping with patient safety principles Completes initial assessment according to policy. Reassesses patient condition per policy. Interprets and utilizes clinical data in the plan of care. Assesses patient for potential risk factors and intervenes to mitigate risk and prevent harm. Recognizes and integrates patient special needs and individualizes care. Adheres to infection control standards specific to patient care. Assumes accountability for managing the delivery of patient care. Promotes safety in all activities. Acts as a patient advocate and uphold patient rights. Assesses and responds to individual, psychosocial, and spiritual needs of the patient. Administers medications correctly within the restrictions and limitations defined by the New Jersey State Practice Act and the Center’s policies and procedures. Prioritizes and organizes work assignment and adjusts priorities based on changing situations. Promotes and maintains a safe clean and orderly environment. Anticipates potential length of stay or discharge problems. Communicates proactively to the health care team plan of care changes in patient condition, the patient progress, the discharge plan and other relevant information. Participates in discharge planning. Initiates appropriate nursing measures. Communicates and documents change in patients condition to all appropriate individuals. Documents medication use and controlled substance. Appropriately secures patient belongings on admission and throughout discharge. Maintains open collaborative dialogue with the management team. Effectively communicates and interacts with physicians, patients, families and the public. Regularly attends staff meeting, orientations, and in-services. Services on assigned committees. Able to assist with teaching aseptic technique, safety program, infection prevention and control, and relevant nursing topics. Reports promptly and accurately all significant event and problems to the manager. Computer Systems Demonstrates knowledge and the skill understanding and using the Center’s computer system for documentation, charging list reports and inventory. Participates in training classes as needed. Maintains confidentiality of all information in the medical record and assigned computer codes. Professionalism Maintains current knowledge of ambulatory postanesthesia / peri-operative nursing practice. Utilizes opportunities for professional growth by attending continuing education programs. Attends seminars and meetings relevant to PACU / Ambulatory Surgery as requested by the Center. Becomes involved with research, new equipment, procedures for the Center. Maintains and ensures dress code and decorum. Prominently wears name identification badge at all times. Introduces self to patients and patient family members. Promotes good image of Center to patients, physicians, vendors and community. Demonstrates professional behavior by being technically competent, skilled and responsive to the Center's customers in a compassionate, efficient and effective manner. Maintains competencies identified by the Center including but not limited to mandatory education, equipment and skill competency review lists, BLS, ACLS, and PALS as required by patient population. Makes self-knowledgeable as to the contents of the Center's Policy and Procedure Manual. Competently Manages Care of the Post Anesthesia Patient Recovers patients per Recovery Phase I and II policy. Demonstrates knowledge of anesthesia agents. Interprets dysrhythmias, documents, and intervenes appropriately. Keeps family/significant others informed of patient progress. Demonstrates the ability and competency to respond quickly and efficiently in emergency situations. Demonstrates knowledge of surgical emergency preparedness, Malignant hypothermia. Cardiac Arrest, Latex Allergy. Maintains BCLS and code blue competency per policy. Recognizes changes in patient condition and responds appropriately. Reprioritizes and delegates other responsibilities during emergency situations. Functions calmly and efficiently. Proficient in the use of emergency equipment. Checks code cart and emergency equipment according to policy. Documents emergency intervention according to policy. Demonstrates the knowledge of nursing responsibilities regarding anesthesia administration: Able to describe AGA classification code for the surgical patient. Identifies agents and routes used in administration of anesthesia. Identifies risks of all phases of anesthesia and verbalizes nursing actions. General Job functions: Participates in the preparation of the patient for surgery Include as a bullet and other job duties as required. Maintains communication with reception area and O.R.’s to assure efficient movement of patients. Implements and insures that physician orders are performed including orders delegated to other health care professionals. Demonstrates understanding and interpretation of diagnostic measures such as lab tests, radiology exams and EKG. Ensures that the Code carts are fully equipped, defibrillators are in operational readiness and that daily checks are completed. Works flexible hours assuming responsibility and accountability for providing patient care. Maintains knowledge of asepsis, infection control and standard/universal precautions. Reduces chances of nosocomial infection by directing attention to infection preventing and control and environmental safety practices. Conducts patient postoperative follow up calls and completes all documentations within the defined timeframe. Performs preoperative assessments and reviews in a timely manner. Demonstrates the skill to assume charge nurse responsibilities in the absence of the nurse manager as assigned. Maintains confidentiality of all information and the medical record and assigned computer codes. Actively communicates and supports the Organization's Mission, Values, Ethics, Philosophy, Objectives, and Policies and Procedures. Demonstrates an understanding of how the success of the surgery center is linked to the success or failure of the customer process. Demonstrates safe habits in the work place with a concern for the safety of patients, families, and staff. Maintains current knowledge of the Center's Emergency Preparedness protocols and procedures. Applies OSHA standards. Provides a summary of post-op instructions to patients prior to discharge from the center. Identifies strategies to increase competency of team members. Physical Job Requirements: Pushing and pulling, taking frequency and weight into consideration. Physical strength to lift heavy objects, carts, or items, taking frequency and weight into consideration. Physical mobility, which includes movement from place to place on the job, taking distance and speed into account. Physical agility, which includes ability to maneuver body while in place. Dexterity of hands and fingers. Balance is maintained during climbing, bending and/or reaching Endurance (e.g. continuous typing, prolonged standing/bending, walking). Environmental Risks: Chemicals, Chemotherapy and Fumes Radiation Sharps Latex Combative Patients / Visitors Blood-borne Pathogens: Exposure to infectious hazards, blood, body fluids, non intact skin, or tissue specimens. Contact with patients or patient specimens are possible. Unplanned or unexpected exposure. Education, Certification, Computer and Training Requirements: Associates degree required. Bachelor’s degree preferred. New Jersey State Nursing License required. BLS and ACLS required. PALS preferred. 2-4 years experience required. 5+ years preferred. Ability to communicate in English, both orally and in writing required. Strong interpersonal and organizational skills required. Ability to perform diverse work assignments with time limitations with a high degree of accuracy required. Ability to use problem solving, critical thinking and priority setting skills required. Must be able maintain annual competencies. Experience with Standard Office Equipment (Phone, Fax, Copy Machine, Scanner, Email/Voice Mail) preferred. Experience with Standard Office Technology in a Window based environment preferred. PER DIEM Rate: $56.50 Pay Range: $45.14 - $56.44 Hourly The provided compensation range is based on industry standards and salary determinations will be made based on numerous factors including but not limited to years of experience and location of position. About Our Commitment Total Rewards at VillageMD Our team members are essential to our mission to reshape healthcare through the power of connection. VillageMD highly values the critical role that health and wellness play in the lives of our team members and their families. Participation in VillageMD’s benefit platform includes Medical, Dental, Life, Disability, Vision, FSA coverages and a 401k savings plan. Equal Opportunity Employer Our Company provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to, and does not discriminate on the basis of, race, color, religion, creed, gender/sex, sexual orientation, gender identity and expression (including transgender status), national origin, ancestry, citizenship status, age, disability, genetic information, marital status, pregnancy, military status, veteran status, or any other characteristic protected by applicable federal, state, and local laws. Safety Disclaimer Our Company cares about the safety of our employees and applicants. Our Company does not use chat rooms for job searches or communications. Our Company will never request personal information via informal chat platforms or unsecure email. Our Company will never ask for money or an exchange of money, banking or other personal information prior to the in-person interview. Be aware of potential scams while job seeking. Interviews are conducted at select Our Company locations during regular business hours only. For information on job scams, visit, https://www.consumer.ftc.gov/JobScams or file a complaint at https://www.ftccomplaintassistant.gov/ .