Transition of Care II, RN

This position operates on a hybrid work schedule. This position will require 3 days onsite at the Monrovia or Huntington Beach office.

Are you ready to make a lasting impact and transform the healthcare space? We are one of Southern California’s fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth.

Who Are We? ✨

Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members’ culture and values.

Why Join Us? 🏆

We’re on a mission! Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you’ll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation.

Job Summary

The Transitions of Care Registered Nurse II (TOC RN II) serves as an experienced clinical care coordinator responsible for managing members with moderate to highly complex medical, behavioral, and psychosocial needs during transitions across the continuum of care. In addition to providing comprehensive transitions of care services, the TOC RN II functions as a clinical resource and mentor to nursing staff, supports quality improvement initiatives, and assists leadership in promoting evidence-based practices, regulatory compliance, and operational excellence.

The TOC RN II independently manages a complex caseload, collaborates with interdisciplinary teams to resolve barriers to care, identifies opportunities to improve member outcomes, and contributes to organizational initiatives that support CMS compliance, NCQA accreditation, HEDIS and Star Ratings performance, and health equity.

Functions & Job Responsibilities

• Perform comprehensive clinical assessments for members experiencing complex transitions of care following inpatient admissions, emergency department visits, skilled nursing facility stays, rehabilitation services, and other qualifying events.
• Independently manage a complex caseload requiring advanced clinical assessment, critical thinking, and interdisciplinary care coordination.
• Develop, implement, evaluate, and revise individualized transition care plans based on member needs, clinical priorities, evidence-based guidelines, and member goals.
• Complete medication reconciliation, identify complex medication-related concerns, collaborate with providers and pharmacists, and recommend interventions that promote medication safety and adherence.
• Coordinate services across hospitals, physician practices, skilled nursing facilities, behavioral health providers, home health agencies, pharmacies, hospice, palliative care, and community-based organizations.
• Identify members at high risk for readmission, adverse clinical outcomes, or care fragmentation and implement advanced care coordination strategies.
• Serve as a clinical resource for Transitions of Care Registered Nurse I staff by providing guidance on clinical decision-making, documentation standards, care planning, and complex case management.
• Mentor newly hired nurses through clinical coaching, knowledge sharing, and support of departmental orientation activities.
• Participate in interdisciplinary care team (ICT) meetings and provide clinical recommendations that support safe, effective, and member-centered care.
• Collaborate with Medical Directors, Utilization Management, Complex Case Management, Social Work, Pharmacy, Behavioral Health, Quality Improvement, and Provider Relations to resolve complex clinical issues.
• Analyze clinical trends and identify opportunities to improve care coordination, transitions of care workflows, and member outcomes.
• Participate in departmental quality improvement initiatives, process improvement projects, regulatory readiness activities, and corrective action plans.
• Review documentation for accuracy, completeness, and regulatory compliance while promoting documentation best practices.
• Assist leadership in identifying workflow improvements that enhance operational efficiency and member experience.
• Assess social determinants of health and coordinate interventions that address barriers impacting successful care transitions.
• Educate members and caregivers regarding disease management, medication adherence, discharge instructions, preventive care, and self-management strategies.
• Promote culturally competent, trauma-informed, and person-centered care while supporting organizational health equity initiatives.
• Maintain compliance with CMS Medicare Advantage regulations, NCQA accreditation standards, HIPAA requirements, organizational policies, and applicable state and federal regulations.
• Support achievement of departmental productivity, quality, and member satisfaction goals.
• Maintain current clinical knowledge through continuing education and professional development.
• Perform additional duties within the scope of licensure as assigned.