What are the responsibilities and job description for the Transitional Care RN RL129493 position at Metro Assoc.?
Transitional Care RN Full-time
Qualifications
Required:
3 years of experience in ANY of the following:
- Geriatric Care
- Senior Care
- Geriatric/LTC
1 years of experience in ANY of the following:
- Transitional Care
- Care Coordination
ALL of the following valid licenses/certifications:
- Registered Nurse (RN) in California (CA)
- American Heart Association Basic Life Support (AHA BLS)
- Proof of a valid CA driver’s license, personal transportation, good driving record, and auto insurance
Preferred:
PACE Experience (1 years)
1 years of experience in ANY of the following:
- Cardiology
- Wound Care
- Colostomy/Ileostomy
- IV Therapy
Bilingual in Spanish (Yes)
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.
Key Responsibilities
- 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
Schedule and Shift Details
- Full-time position with regular daytime hours, Hybrid
Travel
- Occasional travel may be required
Benefits:
- 401k with Employer match
- Your choice of 6 medical plans, with premium coverage of up to 80% for employees and 75% for all dependents
- Dental, vision, health savings account, flexible spending accounts, short- and long-term disability coverages
- PTO starting at 20 days per year; plus 12 paid holidays per year, and 2 floating holidays per year
- Generous CME/CEU budget and time off, and professional development opportunities
- One-time stipend towards setting up your home office (for remote or hybrid roles)
- Family-friendly policies, including paid new parent leave!
Job Type: Full-time
Pay: Up to $55.00 per hour
Expected hours: No more than 40 per week
Work Location: In person
Salary : $55
