Transitional Care RN
Transitional Care RN
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Salary Not Disclosed
1 Vacancy
Job Description
Transitional Care RN (PACE Program)
Location: 100% OnSite FullTime Daytime Schedule
Position Overview:
We are seeking a dedicated Transitional Care RN to support seamless healthcare transitions for our PACE participants. In this role you will coordinate hospitalizations postacute care and athome support to reduce complications lower hospital readmissions and improve health outcomes for older adults. If you are a missiondriven Registered Nurse looking to make a meaningful difference we invite you to apply and join our team.
Key Responsibilities:
- Conduct thorough evaluations during hospital stays to identify risks for postdischarge complications.
- Visit participants in hospitals and skilled nursing facilities (SNFs) as needed to assess medical and functional status.
- Develop and implement individualized transitional care plans including medication management and followup needs.
- Collaborate with the Medical Director and interdisciplinary team (IDT) on hospital admissions observation stays and SNF placements.
- Attend IDT meetings hospital rounds and SNF care conferences to align discharge planning efforts.
- Arrange necessary postdischarge services such as durable medical equipment medications and community resources.
- Educate participants and caregivers on conditions medications and selfcare strategies.
- Conduct followups via phone telehealth or home visits to monitor recovery and address potential issues.
- Identify highrisk participants and proactively implement strategies to improve outcomes and reduce hospital utilization.
- Maintain comprehensive and accurate documentation of participant assessments plans interventions and communications.
- Support additional duties as needed to ensure participant care needs are fully met.
Schedule and Location:
- FullTime position with standard daytime hours.
- 100% OnSite.
- Occasional travel to hospitals and SNFs required.
Benefits:
- 401(k) with employer match.
- Choice of 6 medical plans with premium coverage (up to 80% for employees and 75% for dependents).
- Dental vision health savings account (HSA) and flexible spending accounts (FSA).
- Short and longterm disability insurance.
- Generous paid time off (PTO) starting at 20 days/year plus 12 paid holidays and 2 floating holidays.
- CME/CEU budget with dedicated paid time off for professional development.
- Onetime stipend for home office setup (for remote/hybrid roles).
- Familyfriendly policies including paid new parent leave.
Qualifications:
- Current RN license in CA.
- Clinical nursing experience; transitional care or case management experience preferred.
- Strong clinical assessment critical thinking and care coordination skills.
- Experience working with older adults or in a PACE SNF hospital or community health setting is highly desirable.
- Ability to work collaboratively within an interdisciplinary team.
- Excellent communication documentation and organizational skills
Employment Type
Full Time
