Transitional Care RN

About the role

As our Transitional Care Nurse (TCN), you will serve as a pivotal leader in the Nebraska Rural Health Transformation Program (RHTP), a specialized, grant-funded initiative dedicated to advancing healthcare delivery in rural communities. You will spearhead our Remote Patient Monitoring (RPM) program, collaborating with clinical vendors to deploy innovative medical technology and provide essential physician oversight for clinical escalation. By streamlining care coordination and strengthening chronic disease management, you will play a critical role in reducing avoidable emergency department visits and readmissions for patients managing conditions like diabetes, COPD, and cardiovascular disease.

Every day you will manage the operational and administrative lifecycle of this grant-funded program, utilizing Epic analytics and predictive metrics to identify high-risk patients. Your daily workflow includes reviewing discharge orders, leading clinical huddles, and facilitating seamless transitions through patient consent, device provisioning, and comprehensive education. You will act as the primary point of contact for patients and interdisciplinary healthcare teams, ensuring that every transition plan is meticulously documented in the electronic medical record and tailored to the patient’s specific home health needs.

Responsibilities

• Lead the Remote Patient Monitoring (RPM) program within the Nebraska Rural Health Transformation Program (RHTP).
• Collaborate with clinical vendors to deploy medical technology and provide physician oversight for clinical escalation.
• Manage the operational and administrative lifecycle of the grant-funded program.
• Use Epic analytics and predictive metrics to identify high-risk patients.
• Review discharge orders and lead clinical huddles.
• Facilitate patient transitions through consent, device provisioning, and education.
• Act as the primary point of contact for patients and interdisciplinary healthcare teams.
• Ensure transition plans are documented in the electronic medical record and tailored to patient needs.
• Bridge the gap between hospital-based care and long-term outpatient recovery.
• Build rapport with patients during bedside consultations.
• Partner with Case Management, nursing staff, and physicians to drive RHTP grant goals.

Requirements

• Active RN License.
• BLS Certification.
• 1-3 years of Clinical RN experience in an acute care setting.
• Bachelor Degree in Nursing preferred.

Where You'll Work

Established by the Sisters of the St. Francis in 1924, CHI Health Good Samaritan is a 268-bed regional referral center in Kearney, Neb. The facility includes an advanced level trauma center with AirCare emergency helicopter transport and an ambulance program providing long-distance and local 911 service. Services offered include cardiac care (including open-heart surgery), a level II neonatal intensive care unit, a nationally accredited cancer center, comprehensive neurosurgery, an advanced orthopedic program, and inpatient and outpatient mental health services at the free-standing Richard Young Behavioral Health facility.

Pay

$32.70 - $48.65 per hour.