Transitional Care RN (PACE Program)

Location: 100% On-Site | Full-Time | Daytime Schedule

Position Overview:

We are seeking a dedicated Transitional Care RN to support seamless healthcare transitions for our PACE participants. In this role, you will coordinate hospitalizations, post-acute care, and at-home support to reduce complications, lower hospital readmissions, and improve health outcomes for older adults. If you are a mission-driven Registered Nurse looking to make a meaningful difference, we invite you to apply and join our team.

Key Responsibilities:

• Conduct thorough evaluations during hospital stays to identify risks for post-discharge complications.
• Visit participants in hospitals and skilled nursing facilities (SNFs) as needed to assess medical and functional status.
• Develop and implement individualized transitional care plans, including medication management and follow-up needs.
• Collaborate with the Medical Director and interdisciplinary team (IDT) on hospital admissions, observation stays, and SNF placements.
• Attend IDT meetings, hospital rounds, and SNF care conferences to align discharge planning efforts.
• Arrange necessary post-discharge services, such as durable medical equipment, medications, and community resources.
• Educate participants and caregivers on conditions, medications, and self-care strategies.
• Conduct follow-ups via phone, telehealth, or home visits to monitor recovery and address potential issues.
• Identify high-risk participants and proactively implement strategies to improve outcomes and reduce hospital utilization.
• Maintain comprehensive and accurate documentation of participant assessments, plans, interventions, and communications.
• Support additional duties as needed to ensure participant care needs are fully met.

Schedule and Location:

• Full-Time position with standard daytime hours.
• 100% On-Site.
• Occasional travel to hospitals and SNFs required.

Benefits:

• 401(k) with employer match.
• Choice of 6 medical plans with premium coverage (up to 80% for employees and 75% for dependents).
• Dental, vision, health savings account (HSA), and flexible spending accounts (FSA).
• Short- and long-term disability insurance.
• Generous paid time off (PTO) starting at 20 days/year, plus 12 paid holidays and 2 floating holidays.
• CME/CEU budget with dedicated paid time off for professional development.
• One-time stipend for home office setup (for remote/hybrid roles).
• Family-friendly policies, including paid new parent leave.

Qualifications:

• Current RN license in CA.
• Clinical nursing experience; transitional care or case management experience preferred.
• Strong clinical assessment, critical thinking, and care coordination skills.
• Experience working with older adults or in a PACE, SNF, hospital, or community health setting is highly desirable.
• Ability to work collaboratively within an interdisciplinary team.
• Excellent communication, documentation, and organizational skills