Transitional Care RN at myPlace Health

What Does Success Look Like As Our Transitional Care Rn?

• Comprehensive Participant Assessment: Conduct thorough evaluations of participants during hospitalizations to identify risks for post-discharge complications and ensure a smooth transition.
• Inpatient Facility Coordination: Visit participants in hospitals or skilled nursing facilities (SNFs) as needed to assess their medical and functional status. Collaborate daily with providers and facility staff on treatment plans, care coordination, and discharge planning.
• Care Transition Planning: Develop and implement individualized transition care plans, including medication management, follow-up appointments, and home care needs, in collaboration with participants, families, and the myPlace interdisciplinary team.
• Utilization and Care Management: Work closely with the Medical Director and interdisciplinary team (IDT) to determine hospital admissions, observation stays, and SNF placements, ensuring appropriate lengths of stay. Enter and manage authorizations to streamline claims processing.
• Interdisciplinary Team Collaboration: Attend IDT meetings, hospital rounds, and SNF care conferences to align on participant discharge planning and ensure coordinated care.
• Discharge Coordination & Support: Arrange for appropriate post-discharge care, including medical equipment, medication delivery, and community support services, to prevent readmissions and align with participants’ care goals.
• Participant & Caregiver Education: Educate participants and caregivers about medical conditions, treatment plans, medication adherence, and self-care strategies. Serve as the primary point of contact for guidance during the transition period.
• Ongoing Follow-Up & Monitoring: 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.
• Complex Case Management: Identify high-risk cases, anticipate potential challenges, and implement solutions to improve health outcomes and reduce hospital utilization.
• Effective Communication & Documentation: Maintain accurate and up-to-date records of participant assessments, care plans, interventions, and all communication with healthcare providers and team members.
• Embrace flexibility and teamwork: Step in to support additional responsibilities as needed, ensuring our participants receive the highest quality care and our team thrives together.

What Does An Ideal Candidate Look Like?

• Registered Nurse (RN) License: Active, unrestricted RN license in California.
• Clinical Experience: Minimum 3 years of experience caring for medically complex or older adult populations preferred. Experience with care coordination and managing multiple participant cases is a plus.
• Specialized Skills: Strong clinical acumen in geriatrics, cardiology, or other relevant specialties. Prior experience in wound care, IV therapy, phlebotomy, colostomy/ileostomy care is a plus.
• Care Coordination Expertise: Familiarity with managed care, quality improvement, risk management, and interdisciplinary team collaboration.
• Technology Proficiency: Experience with electronic health records (EHR) and healthcare technology platforms.
• Passion for Mission-Driven Work: Dedicated to improving healthcare outcomes for high-risk seniors and frail older adults.
• Excellent Communication Skills: Ability to effectively engage with participants, families, and healthcare professionals both verbally and in writing.
• Strong Problem-Solving Abilities: Proactively identifies challenges and implements effective solutions to support participant health and well-being.
• Adaptability & Teamwork: Thrives in fast-paced, dynamic environments and is comfortable working across multiple clinical settings.
• Active Listening & Conflict Resolution: Skilled at understanding participant needs and addressing concerns with empathy and professionalism.
• CPR/BLS Certification: Proof of current certification or ability to obtain within 30 days of hire.
• Alzheimer’s Certification: Preferred but not required.
• Language Skills: Bilingual in English and Spanish is preferred.
• Transportation & Compliance: Valid CA driver’s license

The Physical Requirements

• Move freely and safely throughout a variety of care environments, including participant homes, clinics, and skilled nursing facilities.
• Stand, walk, bend, squat, and reach for extended periods during participant assessments, medication administration, and care coordination tasks.
• Lift, transfer, and assist participants as needed—up to 50 pounds—with the use of appropriate body mechanics or mobility equipment.
• Perform fine motor tasks, including taking vital signs, administering medications, and using clinical tools and devices.
• Drive between locations as needed to conduct home visits or attend care transition meetings (requires a valid driver’s license, insurance, and reliable transportation).
• Use a computer and EMR system for prolonged periods for documentation, communication, and care planning.
• We prioritize safety and provide appropriate equipment and training to support your well-being as you care for others.

The Work Environment

• Participant Homes: You’ll regularly travel to participants' residences to assess their needs, ensure safe transitions from hospitals or facilities, and provide in-home support.
• Assisted Living & Skilled Nursing Facilities (ALFs & SNFs): You’ll collaborate with facility staff to support participants during transitions, monitor care plans, and coordinate discharges.
• Day Center & Clinic: You’ll work onsite at our vibrant day center and medical clinic, participating in team huddles, care planning, and clinical coordination.
• On the Road: Travel is a routine part of the role. You’ll need reliable transportation, a valid driver’s license, and auto insurance to support home and facility visits across the community.
• Collaborative & Mission-Driven: No matter the setting, you’ll be surrounded by a passionate, interdisciplinary care team—working together to deliver compassionate, whole-person care.