What are the responsibilities and job description for the Transitional Care RN position at First Priority Services?
Job Overview
As a Transitional Care RN, you will play a crucial role in coordinating and managing healthcare transitions for our PACE participants. Your expertise will help prevent complications, reduce readmissions, and improve health outcomes for older adults. If you are a dedicated and skilled RN with a passion for mission-driven work, we invite you to apply and make a lasting impact on the lives of our participants.
Duties
- Conduct thorough evaluations of participants during hospitalizations to identify risks for post-discharge complications and ensure a smooth transition
- Visit participants in hospitals or skilled nursing facilities (SNFs) as needed to assess their medical and functional status
- Develop and implement individualized transition care plans, including medication management, follow-up appointments, and home care needs
- Work closely with the Medical Director and interdisciplinary team (IDT) to determine hospital admissions, observation stays, and SNF placements
- Attend IDT meetings, hospital rounds, and SNF care conferences to align on participant discharge planning and ensure coordinated care
- Arrange for appropriate post-discharge care, including medical equipment, medication delivery, and community support services
- Educate participants and caregivers about medical conditions, treatment plans, medication adherence, and self-care strategies
- 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
- Identify high-risk cases, anticipate potential challenges, and implement solutions to improve health outcomes and reduce hospital utilization
- Maintain accurate and up-to-date records of participant assessments, care plans, interventions, and all communication with healthcare providers and team members
- Step in to support additional responsibilities as needed, ensuring our participants receive the highest quality care and our team thrives together
Qualifications
- Valid Registered Nurse (RN) license in the state of practice.
- Experience working with individuals with developmental disabilities is preferred.
- Knowledge of acute pain management practices and techniques.
- Familiarity with primary care principles and assisted living environments.
- Proficient in diagnostic evaluation methods and case management processes.
- Ability to perform specimen collection processing accurately.
- Strong communication skills, both verbal and written, with an emphasis on patient education.
- Commitment to upholding HIPAA standards and maintaining patient confidentiality at all times.
Join our team of dedicated professionals committed to making a difference in the lives of our patients. Your expertise as a Registered Nurse will be invaluable in providing exceptional care.
Job Type: Full-time
Pay: $55.00 per hour
Benefits:
- 401(k)
- Dental insurance
- Health insurance
- Paid time off
- Vision insurance
Medical Specialty:
- Geriatrics
Work Location: In person
Salary : $55
