TRANSITIONAL CARE RN

About myPlace Health

myPlace Health was founded in 2021 by mission-aligned healthcare leaders and organizations that are committed to drastically improving health outcomes, quality and experience for vulnerable older adults and frail seniors. We specialize in providing value-based, comprehensive care and coverage for older adults with significant needs so they can thrive in the homes they love and in the communities they cherish.

Our mission is simple : to enable older adults to live the independent lives they deserve. We pursue this mission through our myPlace PACE (Program of All-Inclusive Care for the Elderly) model, which provides seamless primary care, integrated health plan coverage, personalized social engagement, and customized services delivered in the participant's preferred place.

myPlace Health is building a mission-driven team that shares our passion for redefining the way older adults experience care as they age in place in the community. This is a unique opportunity to take on one of our country's most challenging healthcare problems and join a fast-growing, dynamic team as we prepare to scale our mission to serve more markets.

About This Role

Are you a compassionate, mission-driven nursing professional who thrives in a collaborative environment? Do you seek a critical role in delivering high-quality, integrated care that empowers disabled older adults to live safely and independently?

As a Transitional Care RN at myPlace Health, you will be at the heart of our commitment to providing seamless, patient-centered services across different sites of care. You'll coordinate and manage healthcare transitions for our PACE (Program of All-Inclusive Care for the Elderly) participants, ensuring a smooth and safe journey between settings-including hospitals, skilled nursing facilities, clinic, home, and virtual care. Your expertise will proactively help to prevent complications, reduce avoidable readmissions, reduce emergency department visits, and improve health outcomes.

In this role, you will conduct comprehensive participant assessments, collaborate with the myPlace interdisciplinary team, coordinate with planners and clinicians at our partner facilities, educate families and caregivers, and advocate for participants' needs every step of the way. If you're ready to make a lasting difference and help redefine the care experience for older adults, apply today and be part of a team that truly values your impact!

What Does Success Look Like As Our Transitional Care Rn?

• Comprehensive Participant Assessment : Conduct thorough evaluations of participants during hospitalizations to identify risks for post-discharge complications and ensure a smooth transition.
• Inpatient Facility Coordination : Visit participants in hospitals or skilled nursing facilities (SNFs) as needed to assess their medical and functional status. Collaborate daily with providers and facility staff on treatment plans, care coordination, and discharge planning.
• Care Transition Planning : Develop and implement individualized transition care plans, including medication management, follow-up appointments, and home care needs, in collaboration with participants, families, and the myPlace interdisciplinary team.
• Utilization and Care Management : Work closely with the Medical Director and interdisciplinary team (IDT) to determine hospital admissions, observation stays, and SNF placements, ensuring appropriate lengths of stay. Enter and manage authorizations to streamline claims processing.
• Interdisciplinary Team Collaboration : Attend IDT meetings, hospital rounds, and SNF care conferences to align on participant discharge planning and ensure coordinated care.
• Discharge Coordination & Support : Arrange for appropriate post-discharge care, including medical equipment, medication delivery, and community support services, to prevent readmissions and align with participants' care goals.
• Participant & Caregiver Education : Educate participants and caregivers about medical conditions, treatment plans, medication adherence, and self-care strategies. Serve as the primary point of contact for guidance during the transition period.
• Ongoing Follow-Up & Monitoring : 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.
• Complex Case Management : Identify high-risk cases, anticipate potential challenges, and implement solutions to improve health outcomes and reduce hospital utilization.
• Effective Communication & Documentation : Maintain accurate and up-to-date records of participant assessments, care plans, interventions, and all communication with healthcare providers and team members.
• Embrace flexibility and teamwork : Step in to support additional responsibilities as needed, ensuring our participants receive the highest quality care and our team thrives together.

What Does An Ideal Candidate Look Like?

50 - $60 an hour

What's in it for you?

myPlace Health offers a robust compensation package for this role that includes cash compensation and other total rewards. Base pay is based on several factors including but not limited to education, relevant work and industry experience, certifications, and location of the role. Onsite roles include appropriate geographic adjustments, while remote roles are typically priced off national pay data.

Competitive Incentive Plan : Performance-based incentive plan that is beyond the industry standard

Growth and feedback opportunities : Enjoy two performance reviews each year (if applicable), designed to support your professional development and celebrate your contributions to our team's success!

Preparing you for retirement : 401k with Employer match

Medical Plans to fit your needs : Your choice of 6 medical plans, with premium coverage of up to 80% for employees and 75% for all dependents

Ancillary benefits to meet your other needs : Dental and vision plans to meet your needs of you and your dependents; health savings account, flexible spending accounts, short- and long-term disability coverages, as well as basic life insurance. myPlace is also proud to offer accident, hospital indemnity, and critical illness benefits for our team.

Generous time off : PTO starting at 20 days per year; plus 12 paid holidays per year, and 2 floating holidays per year

Professional Development top of mind : Generous CME / CEU budget and time off, and professional development opportunities

Making your home office comfortable : A one-time stipend towards setting up your home office, if applicable.

Family friendly environment : Family friendly policies, including paid new parent leave and new child care stipend

Your Application

Please submit your resume / CV.

Our Commitment to Diversity, Equity and Inclusion

At myPlace Health, we value the diversity of our team members, and we are committed to building a culture of inclusion and belonging. We pride ourselves to be an equal opportunity employer. People seeking employment at myPlace Health are considered without regard to race, color, religion, sex, gender, gender identity, gender expression, sexual orientation, marital or veteran status, age, national origin, ancestry, citizenship, physical or mental disability, medical condition, genetic information or characteristics (or those of a family member), pregnancy or other status protected by applicable law.

COVID-19 Vaccination Policy

At myPlace Health, we provide safe and high-quality care to our participants. To achieve this, we have a policy that strongly recommends Covid-19 vaccination to keep both our team members and participants safe. Medical and religious exemptions can be granted based upon review of proper documentation. We adhere to all federal, state, and local regulations by obtaining necessary proof of vaccination prior to employment.

Beware of Scams and Fraud

Please beware of scams that solicit interviews or promote jobs for opportunities that are not listed on our website or are not directly related to a job you applied for yourself. Please be advised that myPlace Health will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission by selecting the 'Rip-offs and Imposter Scams' option : https : / / reportfraud.ftc.gov / # /

Salary : $50 - $60