The Mobile Transitions of Care (TOC) Nurse provides mobile care management on behalf of the ACO’s medical homes.  Mobile Care Managers will visit patients at acute and specialty care hospitals to ensure safe transitions of care from inpatient to the medical home setting.  The Care Manager will work with the care teams at each hospital site and medical home.


  • Develop relationships with transition of care staff in inpatient hospitals (general acute and specialty) and Medical Home Care Management staff.
  • Engage with patients during hospitalization focusing on reasons for hospitalization, reinforcing with the patient their care management plan of care, gathering new information to share with the Medical Home Care Manager, or creating a care plan if one does not exist.
  • Completing care management assessment as appropriate, such as Health Risk Assessments, Comprehensive Risk Assessments and Transitions of Care Bundle.
  • Gathering medical home information and sharing it with the hospital care team; sharing information about the hospital stay including appropriate discharge planning document with the medical home.
  • Interfacing with the hospital care team staff responsible for utilization management and discharge planning as well as hospitalists, and the patient’s family support network to identify issues that will need to be addressed to assure an efficient and complete transition of care.
  • Educates and supports the patient in the areas of medication management, follow-up care, signs and symptoms of worsening conditions, functional needs and or home and community based services and advance directives.
  • Participates in care team meetings and Integrated Care Team collaboration as necessary.
  • Works with the patient and medical home to secure a timely follow-up appointment.
  • Communicates outcomes of the above functions to the patient’s medical home care manager on a determined schedule.
  • Participates in training care management staff around Transitions of Care and other related topics; trains care managers one on one as opportunities are identified.
  • Completion of other duties as assigned.


  • Excellent oral, written and interpersonal communication skills.
  • Ability to work independently and as part of a team with a wide range of licensed and unlicensed individuals from a variety of care delivery sites and community agencies
  • Excellent organizational skills.
  • Knowledge and experience with electronic information systems.
  • Knowledge of and experience with systems used to improve population health and disease management.
  • Experience in program development and training/education.
  • Ability to foster teamwork, mentor physicians and staff at all levels throughout an organization.
  • Experience in academic medical centers, safety net/public health hospitals, FQHCs and physician groups.
  • Proficient computer skills


  • Bachelors of Science in Nursing or Associates Degree RN
  • Current State of Illinois licensed Registered Nurse
  • Minimum of 3-5 years of recent nursing experience focused on disease management/care management or care delivery in hospitals, Ambulatory Care, Physician group; professional practice; or combination thereof.
  • Demonstrated knowledge and experience in management of disease processes especially chronic disease states such as diabetes, heart failure, COPD/Asthma, behavioral health and substance abuse.
  • At least 3-5 years leadership, consulting or customer/patient relationship, health coaching experience desired.
  • Nurse Case Management Credentialing (RN-BC) or Certified Case Manager (CCM) desirable
  • Valid Illinois Driver’s License and access to an automobile


This position primarily operates in the community, primarily in hospital inpatient and post-acute settings.  Additionally this position will visit ACO medical homes.  Some required time will be spent in the professional office environment,  and regular attendance are essential functions of the job. This role routinely uses standard office equipment.

To apply, please send your resume and cover letter to