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Transitions Nurse – RN

Health Link•San Francisco, CA
•Onsite

About The Position

Health Link Home Health & Hospice is seeking an experienced Registered Nurse to join its Transitions Department. The Transitions Nurse works with Home Health clinical teams to identify patients whose healthcare needs are changing and help them access an appropriate level of care, services, and support. Potential resources include hospice, palliative care, additional caregiving support, higher levels of care, placement, and other community resources. The nurse provides education, guidance, coordination, and follow-up to patients and families throughout care transitions. A key part of the role is identifying patients who may be appropriate for hospice, providing hospice education and in-person informational visits, and facilitating timely transitions from Home Health to Hospice when appropriate. The position involves on-site and field-based work.

Requirements

  • Current and unrestricted California Registered Nurse (RN) license.
  • Minimum of 1 year of nursing experience.
  • Knowledge of hospice, palliative care, and end-of-life care principles.
  • Strong clinical judgment and ability to recognize changes in patient condition and care needs.
  • Excellent communication and interpersonal skills, including ability to have sensitive conversations with patients and families.
  • Strong organizational, follow-up, and care coordination skills.
  • Ability to work independently and collaborate effectively with multidisciplinary teams.
  • Comfort providing education and presentations to clinical teams and community partners.
  • Valid driver’s license and reliable transportation for patient and community visits.

Nice To Haves

  • Home Health, Hospice, palliative care, care transitions, or case management experience.

Responsibilities

  • Work with Home Health clinicians to identify patients whose changing needs may require additional services or a different level of care.
  • Contact patients and families to understand changing needs, explain options, and coordinate appropriate resources and services.
  • Help patients and families navigate transitions to hospice, palliative care, additional caregiving support, higher levels of care, placement, or other community resources.
  • Maintain communication and follow up with patients and families throughout the transition process.
  • Collaborate with Home Health nurses, therapists, and clinical leadership to identify potential hospice patients and ensure timely follow-up.
  • Provide in-person informational sessions about hospice care, services, benefits, and resources to patients, families, and caregivers.
  • Coordinate transitions from Home Health to Hospice when appropriate.
  • Educate Home Health clinical teams about hospice appropriateness, indicators of decline, changing needs, and when additional services or another level of care should be considered.
  • Provide hospice education and in-services to Home Health teams and community healthcare partners.
  • Collaborate with physicians, nurses, therapists, social workers, Hospice staff, and other healthcare professionals to support appropriate and timely transitions.
  • Serve as a consistent point of contact for patients and families as their healthcare needs change.
  • Maintain accurate and timely documentation of communication, follow-up, resources provided, and transition status.

Benefits

  • Health insurance
  • Dental insurance
  • Vision insurance
  • 401(k) with matching
  • Life insurance
  • Paid Time Off (PTO)
  • Flexible schedule
  • Flexible Spending Account (FSA)

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