California Licensed Transition of Care RN

Job Summary

Managing acute discharge planning and transitions of care case management for PACE participants, the full-time California Licensed Transition of Care RN will work remotely to ensure safe and coordinated returns to the community following hospitalizations or skilled nursing facility stays.

Key responsibilities

• Initiate and manage discharge planning for participants admitted to hospitals or skilled nursing facilities
• Monitor participants post-discharge through proactive outreach and follow-up to ensure care plan adherence
• Document transition-related activities and communicate updates to interdisciplinary care teams and participants

Required qualifications

• Active Registered Nurse (RN) licensure in California
• 2-3 years of clinical nursing experience, with at least 1 year in case management or transitions of care
• Experience working with complex, medically frail, or older adult populations
• Strong knowledge of acute care and community-based resources
• Proficiency with electronic health record systems