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.

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!

Requirements

• 3+years of experience inANYof the following:
• Geriatric Care
• Senior Care
• Geriatric/LTC
• 1+years of experience inANYof the following:
• Transitional Care
• Care Coordination
• ALLof the following valid licenses/certifications:
• Registered Nurse (RN) in California (CA)
• American Heart Association Basic Life Support (AHA BLS)
• Valid CA driver's license, personal transportation, good driving record and auto insurance? (yes)
• Do you live within 10 miles of Downtown LA? (yes)
Preferred
• PACE Experience(1+ years)
• 1+years of experience inANYof the following:
• Cardiology
• Wound Care
• colostomy/ileostomy
• IV Therapy
• Bilingual in Spanish (yes)

Qualification

Associate Degree