Part Time Night Shift Remote Jobs in Wisconsin (NOW HIRING)

• Conduct comprehensive clinical assessments of highrisk patients at discharge and throughout the 30day transitional care period, identifying medical, psychosocial, and environmental risk factors.
• Develop, implement, and continuously update individualized, patientcentered care plans addressing clinical needs, medication management, and followup care.
• Coordinate care and facilitate timely communication among inpatient providers, primary care, specialists, home health agencies, and community resources.
• Serve as the primary point of contact for patients and families, providing education on disease management, medications, symptom monitoring, and escalation protocols.
• Manage a caseload of postdischarge patients and ensure completion of followup appointments, home visits, and adherence to prescribed treatments.
• Lead and participate in interdisciplinary rounds and case conferences, collaborating with physicians, pharmacists, social workers, behavioral health providers, and nursing staff.
• Monitor patient progress through outreach visits, telehealth, and phone contacts, intervening promptly when clinical or psychosocial issues arise.
• Ensure compliance with CMS Transitional Care Management guidelines, Joint Commission standards, and organizational policies through accurate and timely documentation.
• Participate in quality improvement initiatives and identify opportunities to strengthen transitional care workflows and patient outcomes.
• Perform other duties and responsibilities as assigned.

Education

• Bachelor of Science in Nursing (BSN) required.

Certification / Registration / License

• Active, unrestricted Registered Nurse (RN) license.

Work Experience

• Minimum of five years of clinical nursing experience in acute care, discharge planning, postacute care, or transitional care.
• Minimum of three years of experience providing care and patient education to complex populations, including heart failure, COPD, GI bleed, sepsis, or stroke.

Knowledge / Skills / Abilities

• Advanced clinical expertise in complex patient management and transitional care.
• Strong care coordination, critical thinking, and clinical decisionmaking skills.
• Demonstrated leadership in interdisciplinary collaboration and patient advocacy.
• Strong communication skills, including use of motivational interviewing techniques.
• Proficiency with electronic health records, care coordination tools, and telehealth platforms.
• Knowledge of regulatory requirements and reimbursement criteria related to transitional care.
• Strong organizational, analytical, and prioritization skills.
• Commitment to ethical practice, patientcentered care, and continuous professional development.

• Primarily remote work environment with occasional onsite meetings.
• Standard schedule is Monday through Friday, 8:00 a.m. - 4:30 p.m., with potential evening or weekend coverage as needed to support patient transitions and caseload requirements.

Education

• Master of Science in Nursing or related field preferred.

Certification / Registration / License

• Preferred certifications include MedicalSurgical RN (MEDSURGBC), CardiacVascular Nursing (CVBC), or Nursing Case Management (CMGTBC).

Experience

• Additional experience in transitional care or case management preferred.

Knowledge / Skills / Abilities

• Not required beyond minimum qualifications.

All responsibilities and requirements are subject to possible modification to reasonably accommodate individuals with disabilities.
This job description does not state or imply that these are the only duties to be performed. Employees may be required to perform other jobrelated duties as requested.