Rn Jobs in Los Angeles, TX

About The Position

Requirements

• An accredited degree in nursing (RN), Master of Social Work (LCSW), or a master's degree in Speech Language Pathology.
• Active, unencumbered RN, LCSW, or Speech Therapist licensure, or equivalent designation applicable to state regulatory requirements.
• Current CPR certification.
• Compliance with occupational health requirements of the joint venture hospital partner(s).
• Ability to read, analyze, and interpret clinical documentation, professional journals, technical procedures, or governmental regulations.
• Ability to write reports, business correspondence, and procedure manuals, and to present information and respond to questions from leaders, teammates, patients, families, and external parties.
• Strong written and verbal communication skills and the ability to understand, read, write, and speak English.
• Ability to articulate and embrace hospice philosophy.
• Ability to manage multiple projects simultaneously and meet deadlines.
• Ability to design accessible and inclusive learning experiences for a diverse workforce.

Nice To Haves

• Two to three years of experience in care coordination, discharge planning, or healthcare services.
• Hospital, home health, hospice, or post-acute care experience.
• Experience with electronic medical record systems such as Epic and referral platforms.

Responsibilities

• Evaluate patients for home-based and post-acute services using clinical, functional, psychosocial, and environmental factors.
• Review inpatient referrals and prioritize patients using clinical judgment and predictive analytics tools.
• Collaborate with physicians and care teams on appropriate level-of-care decisions and identify patients suitable for value-based post-acute care.
• Coordinate timely, safe, and appropriate hospital discharge planning and develop individualized transition-of-care plans.
• Partner with physicians, advanced practice providers, case management, and nursing teams.
• Arrange post-acute services, including home health, hospice, durable medical equipment, medications, and follow-up care; ensure accurate and timely handoffs to post-acute providers.
• Educate patients and families about post-acute options, care expectations, and available services, supporting informed choice and shared decision-making.
• Educate hospital staff and clinical stakeholders about post-acute pathways, referral processes, value-based care, and appropriate site-of-care selection.
• Act as a liaison between hospital teams and post-acute providers; maintain relationships with physicians, case management, nursing teams, and discharge planners.
• Participate in interdisciplinary rounds, discharge planning meetings, and care coordination discussions, and strengthen referral partnerships.
• When applicable, identify patients appropriate for hospice or General Inpatient (GIP) care; coordinate hospice evaluations, eligibility determinations, and admissions.
• Support end-of-life transitions through clinically timely, patient-centered communication and ensure alignment with hospice eligibility and physician certification requirements.
• Document care coordination activities accurately and promptly in the electronic medical record; manage referrals through designated systems and track referrals, outcomes, and transitions.
• Use clinical decision-support tools and predictive analytics platforms.
• Support value-based enterprise (VBE) performance goals and care coordination strategy, including length of stay, readmissions, mortality, timely initiation of care, referral-to-admit rate, and referral quality and documentation accuracy.
• Participate in quality improvement and workflow optimization and support initiatives to improve post-acute network performance and patient outcomes.

Benefits

• Medical insurance
• Dental insurance
• Vision insurance
• Employer-paid life insurance
• Employer-paid disability insurance
• 401(k) retirement plan
• Paid time off
• Paid holidays
• Mileage reimbursement
• Continuing education support
• Employee Assistance Program
• Career development, leadership pathways, mentorship, and professional development
• Flexible time off
• Tuition reimbursement
• Wellness programs
• Recognition programs