Care Transitions Utilization RN

Compensation: $85,000 - $95,000

Job Type: Full Time

About Vitae Health Systems

Founded in 2018, Vitae Health Systems is one of the largest providers of behavioral health, internal medicine, and podiatry services to residents of Skilled Nursing and Assisted Living Facilities. Headquartered in Chicago, IL, we currently operate in over 10 states and are rapidly expanding throughout the USA.

Job Overview

Vitae Health Systems is seeking an experienced Care Transitions Utilization Nurse (RN) to manage patient needs during the most critical window of care: the transition out of the post-acute setting. Working alongside embedded nurse practitioners who facilitate discharge planning while patients are in the facility, this role provides telephonic outreach and follow-up for residents who transfer to the emergency department or hospital, as well as residents discharged from the skilled nursing facility to the community or to another post-acute setting, with a focus on safe, well-coordinated transitions and reducing avoidable utilization.

This is a hybrid role, with one day per week in the Park Ridge, IL office, reporting directly to the Executive Director of Value-Based Care Clinical Operations.

Key Responsibilities

• Identify emergency department visits and hospital admissions through ADT feeds and NP notifications, and complete a structured review of each event, documenting key details and barriers
• Determine the circumstances surrounding each event and discharge through chart review and provider discussion
• Escalate cases to clinical leadership when defined triggers are met
• Conduct telephonic outreach following discharge to the community or another post-acute setting, building on the discharge plan developed in-house by the embedded NP
• Confirm by telephone that each patient is connected to the appropriate ongoing care, including a community primary care provider where applicable, and has the necessary follow-up care, medications, and resources
• Coordinate with facility staff, community providers, and caregivers to close care gaps; escalate patients who cannot be connected or who show early signs of decline
• Perform telephone assessment and triage using approved protocols to differentiate emergent from non-emergent needs and direct patients to the appropriate resource
• Document each encounter and use SBAR to escalate to an NP, RN, or physician when a call falls outside protocol or clinical judgment requires it
• Maintain accurate review data and prepare trend reports for Clinical Operations; identify patterns in discharges and support case-based learning and focused deep-dive reviews
• Apply QAPI methods to design, test, and track performance improvement projects, and report results to leadership
• Partner with embedded NPs, facility nursing leadership, and the Vitae VBC and Clinical Operations teams; contribute to SOP development and revision as the program matures

Requirements

• Active, unrestricted RN license in Illinois, or eligibility for a compact license as applicable; responsibilities are performed within the scope of the nurse’s license, with escalation as required
• Five or more years of skilled nursing facility experience in a leadership or advanced role, such as ADON, unit manager, shift supervisor, or MDS coordinator
• Working knowledge of SNF operations, Part A skilled stays, change in condition management, care planning, facility discharge processes, and SBAR communication methods
• Hands-on QAPI experience, including root cause analysis, performance improvement projects, and data-driven follow-up
• Demonstrated clinical judgment and comfort with telephone assessment and triage
• Strong documentation, organization, and follow-through, with the ability to manage a high-volume workflow independently
• Proficiency with EMR systems, spreadsheets, and dropdown-based review tools
• Ability to work in a primarily computer and phone-based environment, including prolonged sitting and extended phone use, while managing multiple competing priorities; periodic travel to partner facilities

Preferred Qualifications

• MDS or RAC-CT certification or equivalent experience
• Experience with ACO, value-based care, or care transitions programs, including ACO REACH or LEAD
• Experience with ADT feeds and population health dashboards
• Familiarity with goals of care and advance care planning conversations
• Experience working with nurse practitioners in long term care
• Telephone triage or case management experience

Benefits

• Opportunity to play a meaningful role in advancing value-based care for a high-need Medicare population
• Be part of a rapidly growing organization with a commitment to excellence in healthcare
• Help build clinical programs and SOPs as the care transitions program matures
• Competitive salary and benefits package
• Collaborative and supportive work environment