Description We're growing - Join our award winning culture as we serve members in your area! Under the direction of the Service Utilization Supervisor, the Registered Nurse Transition of Care Specialist (TOCS) serves as the clinical point of contact for complex transitions from hospitals to home, hospitals to residential settings or Skill Nursing Facilities (SNF’s), and SNFs to community living. This role consults with care teams and assists in identifying and addressing discharge barriers to support timely discharge when members are medically stable. Through the work, this role will build relationships with hospital staff, provider stakeholders, DHS, and counties which will support seamless transitions of care for the LCI members to reach their outcomes. The position also oversees the Money Follows the Person (MFP) work, which will maximize funding available to LCI for successful transitions from SNFs to a less restrictive environment. Essential Competencies: - Apply professional nursing judgement when reviewing member records and evaluating the clinical risk and on the care planning process specific to the member’s transition of care needs. - Serve as a resource and collaborate through consultation with LCI’s Care Management Staff to support comprehensive, outcome-based care planning for members who are transitioning into different levels of care. - Maintain accurate, timely, and complete hospitalization tracking data within required spreadsheets, ensuring appropriate clinical review, documentation and submission in accordance with state and organizational requirements - Develop and analyze proactive indicators to address the changing and emerging needs of members. - Assess medical complexity, functional status, and clinical stability when identifying barriers to member discharge planning and proactively address problems through collaboration. - Determine which stakeholders need to be a part of a member’s discharge planning meeting. - Collect, analyze, and utilize data to review clinical trends impacting discharge. - Serve as the point of contact for hospitals to ensure smooth discharges and facilitate any complex discharge meetings to ensure appropriate resources are supporting the transition. as well as - Develop and provide training on new and/or more effective guidance to improve overall experiences with discharge planning from various settings and Money Follows the Person. - Serves as the point of contact with external and internal stakeholders across the counties LCI supports. Excellent communication and organizational skills are needed for this pivotal LCI role. - Provide clinical expertise to help ensure safe, appropriate, and medically informed transitions. - Exhibit maturity, resiliency, and sound judgement when dealing with organizational challenges. - Respond constructively to emotional situations, high pressure, and conflict. - Collaborate with internal stakeholders, including CM Program, CM Practice Departments, Network Relations, and Business/Fiscal, to ensure quality and sustainability outcomes are met, and in alignment with LCI’s Strategic Plan and Goals. - Work in partnership with other internal divisions to monitor, evaluate, and process member discharge planning needs. - Serve as a clinical liaison with community and provider stakeholders to support continuity of care and risk mitigation. - Promote a strong commitment to cross-departmental teamwork. - Collaboratively work with internal departments on policy and processes for transitions of care. - Evaluate levels of risk to the organization, support work to mitigate, and report as needed to the appropriate leadership. Requirements - Current License to practice as a Registered Nurse in the State of Wisconsin. - Bachelor’s degree in nursing strongly preferred - Minimum of two (2) years of skilled nursing experience preferred, ideally in gerontology/disabilities and /or home. - Demonstrates proficiency in applying the Family Care principles. - Strong data analysis and application skills. - Strong evaluation, assessment, and interview skills. - Must demonstrate proficiency in Microsoft Office (Word, Excel, PowerPoint, Outlook). - Must have exceptional verbal and written communication skills. - Must have creative problem solving and critical thinking skills. - Must have excellent organization and interpersonal skills. - Must have strong analytical and negotiation skills. - Ability to develop effective working relationships with providers, external stakeholders, and care management staff. - Current driver’s license, acceptable driving record and proof of adequate insurance required. ------------------------------------------------------------------------------------------------- Lakeland Care is a Wisconsin-based non-profit organization that focuses on creating a world we all want to live in. With long-standing roots as a managed care organization (MCO), we provide long-term care services to eligible elders and individuals with physical and intellectual or developmental disabilities. Currently we serve members in 22 counties and have 11 offices throughout the Central to North East region of Wisconsin. Our Mission Empowering individuals. Strengthening communities. Inspiring futures. Our Vision To create a world we all want to live in. Our Core Values Kindness – We believe kindness is always possible and that no compassionate act is ever wasted. Inclusion – We believe that open hearts and open minds are the only path to a brighter future. Trust – We believe that honesty is still in style and that promises still have power. We are an equal employment opportunity employer functioning under an Affirmative Action Plan. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, disability status, protected veteran status or any other characteristic protected by law. We are an organization that participates in E-Verify.

• Provide excellent quality clinical care on a consistent basis that exemplifies Rivia Mind’s culture, values, and guiding principles • Service and maintain a weekly average standard of 31 patients across self-pay, insurance, and Medicare • Maintain a consistent weekly patient care schedule in alignment with Rivia Mind’s standard productivity expectations • Follow Care Model practices that emphasize continuity of care, high-frequency follow-up appointments, and effective calendar management • Conduct comprehensive intake evaluations and develop curated patient-centered treatment plans • Provide appropriate Psychotherapy practices that leverage various modalities (CBT, DBT, motivational interviewing, etc.) • Provide clinical support & counseling to diverse patient populations in a telehealth environment • Coach patients on how to manage ongoing health conditions and provide therapy to help patients make positive behavior changes • Counsel and provide crisis intervention for patients, including assessment and treatment of emotional and behavioral problems • Comply with clinical standards and adhere to timely and thorough session note documentation • Promote a friendly work culture that encourages a fun, collaborative, and co-learning environment that benefits individuals' well-being, self-improvement, and potential • Perform other related role and team function duties as assigned by department and group leaders

Become a part of our caring community Join a Team That's Redefining Senior Primary Care We are looking for a dedicated and experienced Primary Care Nurse Practitioner or Physician Assistant to join our team on a PRN (as-needed) virtual/remote basis. This is a zero-hour contracted role, ideal for providers looking for flexible scheduling while contributing to high-quality outpatient care. You will manage a variety of health-related concerns, focusing on continuity of care, health maintenance, and disease prevention. You will work remotely for our Hampton, VA Clinic and additional clinics if needed. You will report to our Associate Medical Director for the Tidewater Region. Your Role & Responsibilities - You will work in our team-based care environment. - You will proivde care for patients through virtual visits. - Visit types conducted will focus on Medicare Wellness visits and acute same day visits. - You will collaborate daily with your care team to ensure coordinated, high-quality care. - You will maintain accurate and up-to-date medical histories and records. - Evaluate and treat center patients following standards of care. - Follow level of medical care and quality for patients and monitors care using available data and chart reviews. - Complete all medical record documentation promptly working with a quality- based coder to improve coding specificity. - Follow policy and protocol defined by Clinical Leadership. - Assure personal compliance with licensing, certification, and accrediting bodies. What We're Looking For Required: - You will have a Master's Degree in Nursing or completion of a PA program with board certification. - You will hold an active, unrestricted NP or PA license in the state of practice. - Active DEA license and Medicare/Medicaid provider numbers or ability to obtain DEA license and Medicaid and Medicare numbers - If selected for this role, you will be required to be screened for TB Use your skills to make an impact Scheduled Weekly Hours 1 Pay Range The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $150,000 - $206,300 per year Description of Benefits Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers benefits for limited term, variable schedule and per diem associates which are designed to support whole-person well-being. Among these benefits, Humana provides paid time off, 401(k) retirement savings plan, employee assistance program, business travel and accident. About Us About CenterWell Senior Primary Care: CenterWell Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment and more. Our unique care model focuses on personalized experiences, taking time to listen, learn and address the factors that impact patient well-being. Our integrated care teams, which include physicians, nurses, behavioral health specialists and more, spend up to 50 percent more time with patients, providing compassionate, personalized care that brings better health outcomes. We go beyond physical health by also addressing other factors that can impact a patient’s well-being. About CenterWell, a Humana company: CenterWell is a leading healthcare services business focused on creating integrated and differentiated experiences that put our patients at the center of everything we do. The result is high-quality healthcare that is accessible, comprehensive and, most of all, personalized. As the largest provider of senior-focused primary care, a leading provider of home healthcare and a leading integrated home delivery, specialty, hospice and retail pharmacy, CenterWell is focused on whole health and addressing the physical, emotional and social wellness of our patients. CenterWell is part of Humana Inc. (NYSE: HUM). Learn more about what we offer at CenterWell.com.​ Equal Opportunity Employer It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.

Employment Type: Part timeShift: Description: Home Care & Hospice Virtual Care Center Coordinator Registered Nurse (RN) Build a Career. Make a Difference. Love Where You Work. As a Virtual Care Coordinator RN, you will play a pivotal role in delivering telehealth hospice care, ensuring that patients and their families receive personalized support during critical moments. Utilizing virtual platforms, you will monitor patient conditions, coordinate care plans, and provide real-time guidance to field staff and caregivers. Why Join Us? Start Here. Grow Here. Stay Here. We don’t just offer jobs; we build careers. Many of our nurses stay with us long‑term because they feel supported, valued and empowered to grow. If you’re looking for stability, professional development and purposeful work, you’ve found it. What You Can Expect Consistent & Reliable Workloads - Predictable schedules with steady assignments—no scrambling for hours. Supportive, Nurse-Led Leadership - Accessible managers who understand the field and have your back. Real Career Growth Opportunities - Nearly every leader here started in a field role—advance clinically or step into leadership. Epic EHR System - Efficient documentation and seamless care coordination—less time charting, more time caring. Fast, Respectful Hiring Process - Quick interviews and timely offers because your time deserves respect. Meaningful 1:1 Patient Care - Build real relationships and see the direct impact of your work every day.. What You Will Do: - Conduct virtual assessments and monitor patients' conditions remotely. - Develop and coordinate individualized care plans in collaboration with the interdisciplinary team. - Provide virtual education and support to patients, families, and caregivers regarding symptom management and end-of-life care. - Liaise with field nurses, physicians, social workers, and other team members to ensure comprehensive care delivery. - Respond promptly to urgent virtual consults and triage patient needs effectively. - Utilize telehealth technology to conduct regular check-ins and follow-ups with patients and families. Minimum Qualifications: - 5+ years of Home Care, Hospice, ER and/or Triage RN Experience - Active RN license in a Compact State (eNLC) - BSN required by an approved Nursing education program. - Proficiency in Epic or Home Care EMR Experience - Strong communication and interpersonal skills to build rapport with patients and families virtually - Ability to work independently and as a part of collaborative remote team - Able to adapt to rapid changes to meet business/department needs - Patient/Customer Service Experience About Trinity Health At Home – Southeast Michigan Trinity Health At Home – Southeast Michigan is a trusted member of Trinity Health At Home, a national home care, hospice and palliative care organization serving communities across 11 states. As a faith-based, not‑for‑profit agency, we are committed to caring for patients and families in the place they feel most comfortable—at home. Our services include skilled nursing, physical, occupational and speech therapy and medical social work. We are: ✅ Medicare‑Certified ✅ Joint Commission Accredited 🏆 A Reputation.com 800 Award Winner 2025 & 2026 Learn more at TrinityHealthAtHome.org/Michigan. Our Commitment Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.