Transition of Care RN

📋 Description

• Initiate and manage discharge planning for PACE participants admitted to hospitals, skilled nursing
• Coordinate with inpatient care teams, IDT members, and external network providers to facilitate
• Ensure post-discharge services (transportation, DME, home health, medications, home care, follow-up
• Monitor participants post-discharge through proactive outreach and follow-up calls
• Identify and address social determinants of health and other barriers
• Collaborate with IDT to update care plans and communicate status changes

🎯 Requirements

• Active Registered Nurse (RN) licensure in California (or compact license with California
• 2–3 years of clinical nursing experience, with at least 1 year in case management, discharge
• Experience working with complex, medically frail, or older adult populations
• Strong knowledge of acute care, post-acute care settings, and community-based resources
• Proficiency with electronic health record systems
• Excellent communication, critical thinking, and organizational skills

🎁 Benefits

• Medical/dental/vision insurance
• Short and long-term disability
• Life insurance
• Flexible spending accounts
• 401(k) savings
• Paid time off