Intake RN - Care Transitions

Avail Health•Rockville, MD

2d•Onsite

About The Position

Avail Health is building a technology-enabled Care Transitions Program designed to support Medicare-age patients during one of the most vulnerable periods in their healthcare journey: the transition from hospital to home. The Intake RN serves as Avail Health's primary hospital-based clinical representative, identifying, assessing, and enrolling eligible patients into the Care Transitions Program prior to discharge. This role requires strong clinical judgment to evaluate patient complexity, anticipate post-discharge needs, determine program eligibility, support risk stratification, and recommend the appropriate care pathway and level of interdisciplinary support. Working closely with hospital care management teams, physicians, nurses, social workers, discharge planners, caregivers, and community partners, the Intake RN helps ensure high-risk Medicare patients receive the appropriate level of support during the transition from hospital to home while balancing program resources and team capacity. As a key member of a newly developing care model, this role also provides frontline insight that helps shape workflows, operational processes, and program growth.

Requirements

Active, unrestricted Maryland RN license in good standing
Minimum 5 years of clinical nursing experience
Experience supporting transitions of care, discharge planning, care management, or complex care coordination for high-risk populations
Experience providing care within patients' homes through home health, hospice, palliative care, house calls, community-based care management, or similar care models
Demonstrated clinical judgment in patient assessment, triage, discharge planning, transitions of care, or complex care management settings
Ability to independently evaluate patient complexity and anticipate post-discharge support needs
Strong clinical assessment, critical thinking, and problem-solving skills
Excellent communication and relationship-building skills
Ability to manage multiple competing priorities within a fast-paced environment
Strong organizational skills and attention to detail

Nice To Haves

Hospital care management, discharge planning, transitions of care (TOC), transitional care management (TCM), or hospital readmission reduction experience
Emergency Department, observation, triage, rapid assessment, or other high-acuity care coordination experience
Experience working with Medicare-age populations with complex medical, behavioral health, or psychosocial needs
Experience supporting startup healthcare organizations, new program launches, or rapidly evolving care delivery models
Experience working with interdisciplinary care teams across clinical and operational functions
Familiarity with technology-enabled care models and workflow-driven care delivery

Responsibilities

Patient identification, assessment, and enrollment into the Care Transitions Program
Clinical assessment, eligibility determination, and risk stratification
Care pathway and resource recommendations based on patient complexity
Hospital stakeholder relationships and care coordination partnerships
Seamless handoff of enrolled patients to Avail's interdisciplinary Care Transitions team
Documentation, compliance, and operational excellence throughout the intake process
Frontline feedback supporting workflow refinement and program development
Participate in hospital huddles, rounds, discharge planning meetings, and care coordination activities to identify patients eligible for the Care Transitions Program
Conduct bedside patient assessments and enrollment conversations
Evaluate medical, behavioral health, psychosocial, caregiver, and environmental factors impacting successful transitions of care
Determine program eligibility and appropriate risk stratification levels
Recommend care pathways, visit modalities, and interdisciplinary team resources based on patient complexity and anticipated support needs
Coordinate with caregivers, family members, and authorized representatives as appropriate
Collaborate closely with Nurse Practitioners, RN Care Managers, Social Work Care Managers, Care Coordinators, and program leadership
Facilitate timely information exchange between hospital and community-based care teams
Connect patients with appropriate community resources and support services
Maintain accurate documentation within hospital systems and Avail technology platforms
Participate in workflow refinement and continuous process improvement efforts as the program evolves