About the position Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand with heart at its center, our purpose sends a personal message that how we deliver our services is just as important as what we deliver. Our Heart At Work Behaviors support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient, and affordable. This is a full-time telework position. Hours for this role are Monday-Friday 8a-5p in the time zone of residence. 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 a life-changing impact on our members, who are enrolled in Care Management 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. 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. Under the direction of a Registered/Licensed RN, the TOC Coach ensures the member experiences a seamless transition to their next care setting and facilitates post-discharge goal attainment. Responsibilities include completing post-discharge questionnaires, ensuring medication understanding, benefit education, monitoring members for alerts or changes in condition, and facilitating overall care coordination with the care team to ensure optimal wellness. The TOC Coaches are frontline advocates for members who cannot advocate for themselves, focusing on holistic assessments to identify needs for referrals to clinical resources for assistance in functionality. Responsibilities • Complete outreach cadence calls and post-discharge questionnaires within required compliance driven timelines. , • Utilize weekly and daily reporting to identify utilization for the purpose of reducing Emergency Department Utilization and 30-day hospital readmissions. , • Follow members identified as inpatient in hospitals (whether planned or unplanned admission) and throughout the subsequent care continuum until the member can return to prior level of functioning in the community. , • Facilitate Interdisciplinary Care Team Meetings with Social Services, Care Management, PCP and other key players to discuss service needs and support safe transitions. Requirements • 2+ years LPN or LVN nursing experience , • Active and unrestricted compact LPN or LVN licensure in state of residence Nice-to-haves • Bilingual (Spanish) a plus! , • Self-motivated, energetic, detail-oriented, highly organized, tech-savvy , • Discharge planning experience , • Advanced 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 Benefits • Full range of medical, dental, and vision benefits , • 401(k) retirement savings plan , • Employee Stock Purchase Plan , • Fully-paid term life insurance plan , • Short-term and long-term disability benefits , • Numerous well-being programs , • Education assistance , • Free development courses , • CVS store discount , • Discount programs with participating partners , • Paid Time Off (PTO) or vacation pay , • Paid holidays throughout the calendar year Apply Job! Apply To this Job