Transitional Care RN

myPlace Health•East Compton, CA

18h•$50 - $60

About The Position

As a Transitional Care RN at myPlace Health, you will be at the heart of our commitment to providing seamless, patient-centered services across different sites of care. Youâll coordinate and manage healthcare transitions for our PACE (Program of All-Inclusive Care for the Elderly) participants, ensuring a smooth and safe journey between settingsâincluding hospitals, skilled nursing facilities, clinic, home, and virtual care. Your expertise will proactively help to prevent complications, reduce avoidable readmissions, reduce emergency department visits, and improve health outcomes. In this role, you will conduct comprehensive participant assessments, collaborate with the myPlace interdisciplinary team, coordinate with planners and clinicians at our partner facilities, educate families and caregivers, and advocate for participantsâ needs every step of the way. If you're ready to make a lasting difference and help redefine the care experience for older adults, apply today and be part of a team that truly values your impact!

Requirements

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.
Specialized Skills: Strong clinical acumen in geriatrics, cardiology, or other relevant specialties.
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.
Transportation & Compliance: Valid CA driverâs license

Nice To Haves

Experience with care coordination and managing multiple participant cases is a plus.
Prior experience in wound care, IV therapy, phlebotomy, colostomy/ileostomy care is a plus.
Alzheimerâs Certification: Preferred but not required.
Language Skills: Bilingual in English and Spanish is preferred.

Responsibilities

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 participantsâ 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.