Transitional Care RN

Overview
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.
● Full-time position with regular daytime hours, 100% on-site.

Travel
● Occasional travel may be required

Benefits:
● 401k with Employer match
● Your choice of 6 medical plans, with premium coverage of up to 80% for employees and 75% for all dependents
● Dental, vision, health savings account, flexible spending accounts, short- and long-term disability coverages
● PTO starting at 20 days per year; plus 12 paid holidays per year, and 2 floating holidays per year
● Generous CME/CEU budget and time off, and professional development opportunities
● One-time stipend towards setting up your home office (for remote or hybrid roles)
● Family friendly policies, including paid new parent leave!

Required Qualifications
• 3+ years of experience with Senior Care or Geriatric/LTC or Geriatric Care
• 1+ years of experience with Transitional Care or Care Coordination
• Valid American Heart Association Basic Life Support (AHA BLS) and Registered Nurse (RN) in California (CA) certifications/licenses
• Have you spoken to a recruiter via phone regarding this position?
• Proof of a valid CA driver’s license, personal transportation, good driving record and auto insurance?
• Do you live within 10 miles of Downtown LA?

Preferred Qualifications
• 1+ years of experience with colostomy/ileostomy or IV Therapy or Wound Care or Cardiology
• Bilingual in Spanish
• 1+ years of experience with PACE Experience

Benefits
401(k), CME Reimbursement, Flexible Spending Account (FSA) , Full Benefits, Health Savings Account (HSA) , Paid Time Off, Paid Training and Development, Professional Development Opportunities

Company
Our client was founded in 2021 by mission-aligned healthcare leaders and organizations that are committed to drastically improving health outcomes, quality and experience for vulnerable older adults and frail seniors.

We are a multidisciplinary team of clinicians, operators, technologists, entrepreneurs, and builders who are united around our mission and seek meaningful careers that improve the lives of some of the most vulnerable members of our community.