AIDS Healthcare Foundation

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Transition of Care Nurse

Transition of Care Nurse

Req No 
Job Locations 
US-CA-Los Angeles
Managed Care
Regular Full-Time

More information about this job




Does the idea of doing something that really makes a difference in people’s lives while being well-compensated intrigue you? Are you looking to work for an organization that encourages growth and success from each and every one of its employees?


If so, AIDS Healthcare Foundation is the place for you!


Founded in 1987, AIDS Healthcare Foundation is the largest specialized provider of HIV/AIDS medical care in the nation. Our mission is to provide cutting edge medicine and advocacy, regardless of ability to pay. Through our healthcare centers, pharmacies, health plan, research and other activities, AHF provides access to the latest HIV treatments for all who need them.


AHF’s core values are to be:


• Patient-Centered

• Value Employees

• Respect for Diversity

• Nimble

• Fight for What’s Right



STILL INTERESTED? Please continue!


AIDS Healthcare Foundation is seeking a full-time, Transition of Care Registered Nurse to assist our Managed Care Division located at the following address:


1001 North Martel Avenue

Los Angeles, California 90046


Hours of Operations: 

Monday - Friday, 8:30am-5:30pm



The Transition of Care Registered Nurse is responsible for projecting and integrating the Mission and Core Values of the organization in the provision care management services to members of the AHF/AHFMCO Medicare and Medicaid health plans of California.


Key responsibilities include leading the transition of care process, providing culturally and linguistically sensitive care management services to the HIV/AIDS special needs population enrolled in the Medicare and Medicaid health plans under the supervision of the Director of Care Coordination Programs or designee , completing the transition of care assessment and medication reconciliation, participating in the gathering and transmission of information and data to the RN Care Team Manager regarding care planning, participating in interdisciplinary team meetings, participation in activities that increase understanding of the communities served by the AHF/AHF MCO and going the extra mile to assure members have access and knowledge of their health plan benefits, community benefits, treatment plan, and medication adherence.


Essential Duties & Responsibilities

Duties and Responsibilities include but are not limited to the following

  • Develops and maintains knowledge of Medicare MAPD transition of care guidelines and Medicaid/MediCal transition of care requirements at all times. Executes TOC responsibilities in concert with the Medicare and/or Medicaid-Medi-Cal requirements.
  • Documents all TOC activities in the care management system in a timely manner.
  • Keeps appropriate Interdisciplinary Team members informed of member transition progress.
  • Receives notification from UM Department that members are either transitioning or have transitioned their care into a facility. Collaborates with UM and receives initial transition documentation from UM on transitioning members. Begins transition planning as appropriate.
  • Collaborates with transitioning facility staff to assure discharge planning and physician discharge orders have been implemented and confirmed as executed prior to the patient’s discharge
  • Assures that a patient’s ARV medication regimen is available during facility stay
  • Collaborates with and plays a lead role to re-engage the member during and following a medical, rehabilitation and behavioral inpatient admission through reassessment, including medication reconciliation, coordination of transition of care, including PCP appointment, supplies, services and transportation as needed.
  • Assures post-discharge PCP and specialist appointments are scheduled and attended by member within one week of discharge from an inpatient facility.
  • Provides Transition of Care assessments in the inpatient setting including educating the patient on their discharge plan, i.e., what to expect, how to manage their condition and the reporting of “red flag” conditions to their PCP and RNCM, medications prescribed, what they were prescribed for and how to take them, reconciling pre and post hospitalization medication lists, keeping personal health record/notes and what and when to report symptoms to the TOC nurse, RNCTM or PCP, as well as collaborating with the RNCTM (Social Worker, if appropriate) to assure follow-up home/ transition facility visits and calls to patients following the transition to a new level of care to assure plan is progressing and PCP visit has occurred.
  • Assures that Member and family/significant other understand the discharge and transition plans, post-discharge appointments and RNCTM/TOC contact for questions and advise.
  • Intercedes directly on member behalf when necessary to assure smooth transition process, e.g., assuring delivery of prescription medications, authorizing care/services based upon indications and appropriateness of care criteria, substituting home health vendors when care or supply commitments for transition are not met, etc.
  • Collaborates with the Health Care Center and external network PCPs, the Care Team and other practitioners to ensure members are well supported and managed within the Patient Centered Medical Home of the Chronic Care Model.
  • Collaborates with ASO's, PAC Providers and other Community Services as necessary to ensure appropriate access to service and follow up on the results to such referrals.
  • Completes assessments and re-assessments timely for members as needed during transition of care, updates RNCTM on assessment findings, discharge plan and changes to patient individual care plan.
  • Assures Care Plan has been sent by the UM Department to facility and PCP within 1 day of admission
  • With the member and member’s family, if appropriate, establishes and updates patient centered long term and short term goals for care and self management.
  • With the input of the member, family and medical team, creates an appropriate and timely individual care plan and updates to existing care plan to assist the member to achieve the established goals.
  • Maintains current knowledge of MCO benefit structure, policies and procedures related to authorization of services. Working knowledge of creating a wrap-around solution to address member’s needs using appropriate MCO benefits and available ASO and community resources.
  • Works to deliver care management services in an efficient and cost effective manner.
  • Communicates the care plan to the Primary Care Physician, member and others in the Health Home.
  • Revises the Care Plan following hospitalization of the member
  • Coordinates with RNCTM post discharge visit. TOCRN and/or RNCTM meets with member face to face in the home or at physician appointments to assure that discharge plan supplies and/or care linkages are in place, complete transition of care assessments, surveys and other contacts, as necessary.
  • Provides health education regarding disease process, self-care strategies and tactics, medications, medication adherence, community resources and benefits.
  • Collaborates with AIDS Service Organizations and other community resources, as necessary, to ensure appropriate access to care and services.
  • Maintains current clinical knowledge of HIV/AIDS medications and treatment regimens.
  • Maintains at least the minimum performance and productivity standards.
  • Completes a minimum of three recommended AIDS related in-services, trainings or one conference per year.
  • Obtains and maintains HIV/AIDS disease/treatment general knowledge proficiency
  • Reports urgent member issues and barriers to care to the Primary Care Provider and the Director of Care Coordination Programs or designee as appropriate.
  • Advocates for member needs with medical provider, RN Care Team Manager and community.
  • Participates in ICT meetings.
  • Collaborates with Plan Health Educator to develop Member education materials for medication adherence tracking, post discharge condition management, and other relevant transition educational tools and surveys.
  • Reports all complaints and grievances per grievance policy.
  • Other duties as assigned to ensure team goals are met.


Management Responsibilities


  • Collaborates with the Director of Care Coordination Programs or their designee and the Care Team members on the day-to-day care management of members who have been or are currently inpatients.
  • Participates in team conferences regarding inpatients and transition of care assessments with the Interdisciplinary Team.
  • Collaborates with the Plan Medical Director, Director of Care Coordination Programs and/or designee on member clinical, satisfaction, utilization and cost issues.