Transitional Care Registered Nurse

As a Transitional Care RN, you will play a crucial role in coordinating and managing healthcare transitions for our PACE participants. Your expertise will help prevent complications, reduce readmissions, and improve health outcomes for older adults. If you are a dedicated and skilled RN with a passion for mission-driven work, we invite you to apply and make a lasting impact on the lives of our participants.

Key Responsibilities

• Conduct thorough evaluations of participants during hospitalizations to identify risks for post-discharge complications and ensure a smooth transition
• Visit participants in hospitals or skilled nursing facilities (SNFs) as needed to assess their medical and functional status
• Develop and implement individualized transition care plans, including medication management, follow-up appointments, and home care needs
• Work closely with the Medical Director and interdisciplinary team (IDT) to determine hospital admissions, observation stays, and SNF placements
• Attend IDT meetings, hospital rounds, and SNF care conferences to align on participant discharge planning and ensure coordinated care
• Arrange for appropriate post-discharge care, including medical equipment, medication delivery, and community support services
• Educate participants and caregivers about medical conditions, treatment plans, medication adherence, and self-care strategies
• Regularly check in with participants post-discharge via phone, telehealth, or home visits to assess progress, address concerns, and proactively intervene to prevent complications or readmissions
• Identify high-risk cases, anticipate potential challenges, and implement solutions to improve health outcomes and reduce hospital utilization
• Maintain accurate and up-to-date records of participant assessments, care plans, interventions, and all communication with healthcare providers and team members
• Step in to support additional responsibilities as needed, ensuring our participants receive the highest quality care and our team thrives together

Schedule and Shift Details / Location.

Travel

Benefits :

Requirements

Preferred