Registered Nurse Transitions-of-Care Coordinator

Skillcloud HCM•South Portland, ME

1d•$40 - $46•Onsite

About The Position

Chest Medicine Associates is seeking a full-time Registered Nurse to serve as the RN Transitions-of-Care Coordinator-Pulmonary Medicine to serve as a central resource for patients, families, physicians, and hospital teams, ensuring timely follow-up, seamless communication, and coordination of complex pulmonary care. This is a full-time, Monday–Friday daytime position with no routine evening, weekend, or holiday responsibilities. This position will be grant-supported for two years and may be contingent on renewal of grant funding.

Requirements

Registered Nurse with an active, unrestricted Maine license.
Bachelor of Science in Nursing (BSN).
Current American Heart Association Basic Life Support (BLS) certification.
Minimum of two years of clinical nursing experience.
Strong clinical assessment and telephone triage skills.
Excellent communication and interpersonal skills.
Proficiency with electronic health record systems and Microsoft Office applications

Nice To Haves

Experience in pulmonary medicine, hospital medicine, case management, care coordination, and/or transitions of care is preferred
Experience caring for patients with COPD, ILD, asthma, bronchiectasis, or other chronic respiratory diseases is preferred.
Familiarity with pulmonary rehabilitation, home oxygen therapy, durable medical equipment, and insurance authorization processes is preferred.

Responsibilities

Identify hospitalized pulmonary patients appropriate for transitions-of-care services, with emphasis on COPD and ILD.
Collaborate with inpatient teams, case management, respiratory therapy, pharmacy, and primary care providers and coordinate timely pulmonary follow-up appointments and diagnostic testing.
Contact patients within 24–72 hours of discharge to assess recovery, reinforce discharge instructions, and identify barriers to care.
Perform medication reconciliation and reinforce inhaler technique and medication adherence.
Assess oxygen, nebulizer, CPAP/BPAP, and other durable medical equipment needs.
Facilitate referrals to pulmonary rehabilitation, smoking cessation, home health, palliative care, and community resources.
Monitor for clinical deterioration and collaborate with providers to facilitate intervention.
Coordinate referrals for EBUS and robotic bronchoscopy.
Schedule procedures and required pre-procedure testing.
Ensure required imaging and diagnostic studies are available.
Track patients from referral through pathology results and treatment planning.
Coordinate post-procedure follow-up and collaborate with the lung cancer screening program to facilitate timely evaluation of abnormal screening findings.
Perform pulse oximetry testing, nebulizer treatments, medication administration, and other nursing procedures within scope of practice.