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!

• 3+ years of experience in ANY of the following:
• Geriatric Care
• Senior Care
• Geriatric/LTC
• 1+ years of experience in ANY of the following:
• Transitional Care
• Care Coordination

• ALL of 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 in ANY of the following:
• Cardiology
• Wound Care
• colostomy/ileostomy
• IV Therapy

• Bilingual in Spanish (yes)