Transitional Registered Nurse (PACE)

Responsibilities

• Conduct thorough evaluations of participants during hospitalizations to identify risks for post-discharge complications and support a smooth transition.
• Visit participants in hospitals or skilled nursing facilities (SNFs) as needed to assess medical and functional status and collaborate with providers and facility staff on treatment plans, care coordination, and discharge 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.
• 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.
• Attend IDT meetings, hospital rounds, and SNF care conferences to align on participant discharge planning and ensure coordinated care.
• Arrange appropriate post-discharge care, including medical equipment, medication delivery, and community support services, to prevent readmissions and align with participants’ care goals.
• Educate participants and caregivers about 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: 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 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 communication with healthcare providers and team members; embrace flexibility and teamwork to support additional responsibilities as needed.

Qualifications & Experience

• Registered Nurse (RN) License: Active, unrestricted RN license in California.
• 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.
• CPR/BLS Certification: Proof of current certification or ability to obtain within 30 days of hire.
• Valid CA driver’s license.
• Alzheimer’s Certification: Preferred but not required.
• Tuberculosis Screening Policy: Proof of negative screening within the last year or ability to provide proof of a negative screening upon hire.