341,589 Transitional Care Nurse jobs in the United States
Transitional Care Nurse
Posted today
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Full-time
Description
Longleaf Hospice and Palliative Care is locally owned with offices located in Atlanta, Covington and Roswell, offering end-of-life care to those with life limiting illnesses in the communities we serve. We believe that this very special care is best provided by professionals who live and work in the community they serve. At Longleaf Hospice and Palliative Care, we integrate and address the diverse, seen and unseen needs of patients and their families.
The Transitional Care Nurse provides direct nursing care to patients, care coordination and education to patients, families and staff in general inpatient units in accordance with established policies, procedures, and protocols. This position involves patient assessment, establishment of an individualized plan of care, discharge planning and communication with the hospice physician to meet patient/caregiver needs.
SHIFT: 7 ON / 7 OFF; 7:00AM - 7:00PM, EVERY OTHER WEEK
RESPONSIBILITIES:
- Completes general inpatient (GIP) admissions, collaborating with the hospital physician and the Hospice physician to assist in determining the patient's clinical eligibility for hospice care
- Makes visits to assess GIP patients daily while patient is in the hospital
- Participates and plans discharge for those GIP patients that will be transitioned home with hospice, assisting with and completing appropriate paperwork as needed
- Provides education regarding home hospice care and home palliative care to patients that are in the hospital
- Provides education to the hospital staff regarding hospice and palliative care
- Implements and monitors patient care plans
- Monitors, records and communicates patient condition as appropriate
- Serves as primary coordinator of all disciplines for well-coordinated patient care
- Participates in bi-weekly interdisciplinary group (IDG) meetings
- Assesses needs of patient and family and provides education and support based on age, culture and willingness to learn
- Performs home hospice admissions as needed
- Pronounces patients and performs other routine nursing visits when requested
- Participates in Quality Assessment Performance Improvement (QAPI) program and Hospice sponsored in-services
- Performs job duties in accordance with Nurse Practice Act
- Other duties as assigned
Requirements
- Licensed as a registered nurse in the state of Georgia
- Graduate from an accredited school of nursing
- Minimum of five (5) year's nursing experience
- Minimum of two (2) years' experience in hospice/home care preferred
- Certified Hospice and Palliative Care Nurse (CHPN) preferred
- Critical thinking skills and decisive judgment required
- Works under minimal supervision
- Ability to work in a stressful environment required
- Good verbal and written communication and problem-solving skills required
- Responsible valid driver's license
- Reliable, insured, automobile for making home visits required
Transitional Care Nurse
Posted 8 days ago
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Job Description
7/28/2025
Job Code:
Tran Care Nur
Location:
MLK Community Hospital & Foundation
Address:
1680 E. 120th St.
City:
Los Angeles
State:
CA
Country:
United States of America
Category:
Care Management/Social Services
Pay Rate Type:
Hourly
Salary Range (Depending on Experience):
$46.82 - $72.57
If you are interested, please apply and send your resume to
POSITION SUMMARY
The Transitional Care nurse (TCN) will ensure the coordination and continuity of healthcare as patients transition between different locations or levels of care. The TCN will assist with complex patients, focus on high hospital utilizers, chronically ill and educate patients and family caregivers to determine the root cause to poor health outcomes that may lead to readmission to the hospital. The TCN will work with the Manager of Case Management, Care Managers and hospitalists to determine a safe discharge plan and ensure patient's continuity of care upon discharge.
ESSENTIAL DUTIES AND RESPONSIBILITIES
* Responsible for post discharge contact on a case-by-case concern with Medicare, other payers, and other identified complex patients, observation and inpatient, to determine that a safe discharge plan has been fully implemented.
* Works with the Manager of Post-Acute Services Care Networks, Care Management Manager, Social Work and other members of the CM team to identify patients requiring follow up assessments and identification of criteria for patients requiring follow up phone calls or other contact.
* Assess identified cases and utilize the information and available benefits/resources to assist the patient, family/caregiver and provider.
* Document all activities specific to interventions for patients contacted in the electronic medical record.
* Coordinates services in an effort to provide integrated health services for each patient and provide benefit and health information to each patient so they are able to make informed health decisions.
* Assesses patient needs and make referral to any needed follow up services such as but not limited to MLKCH PDC, community resources, primary care provider, disease management, or other services.
* Promote the mission and core values of MLKCH.
* Document each call with all pertinent information along with interventions performed in a call log.
* Acts as a consultant for the Transitional Care Navigator Lead or other members of the CM team.
* Participates in performance improvement projects, initiatives and performs data collection for measurement of projects as assigned.
* Works closely with Post-Acute Services to ensure that patients in settings other than home are appropriately placed post recuperative.
* Has authority to add or extend services as needed to prevent readmission to MLKCH.
* May participate in interdisciplinary discharge planning teams to ensure smooth transition from inpatient to outpatient services.
* Meets regularly with CM Leadership & Post-Acute Network Manager to identify opportunities or trends to improve patient care.
* Acts as CM with any recently acquired insurance; communicates and educates patient and family as needed in obtaining assistance from PCP or PDC.
* Must utilize Translator assistance devices as needed to improve communications with patients and families.
* Work with management to identify and vet potential post-acute service providers, as well as complete site visits to skilled nursing facilities with management to ensure MLK funded patients are receiving all necessary post-acute services.
* Perform other duties as assigned.
POSITION REQUIREMENTS
A. Education
* BSN required.
* CCM or ACM certification within 2 years of hire.
B. Qualifications/Experience
* Three (3) years of experience in Care Management either acute care or telephonic Care Management/Disease Management.
* Current California Nursing license.
* Current Basic Life Support (BLS) for Health Care Providers from the American Heart Association.
* Valid unrestricted CA Driver's License and valid proof of vehicle insurance.
* Prior case management experience in an acute care setting, medical office or health advice RN preferred.
* Bi-lingual Spanish preferred.
C. Special Skills/Knowledge
* Proficient to expert computer skills utilizing Microsoft Office especially Word and Excel
* Must be customer service driven and be resourceful while utilizing high level of critical thinking skills.
* A team player that can follow a system and protocol to achieve a common goal
* Highly organized and well developed oral and written communication, problem-solving, and decision-making skills.
#LI-YD1
MLKCH Video
Transitional Care - Nurse Practitioner
Posted today
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Transitional Care - Nurse Practitioner
Posted 8 days ago
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Job Description
Transitional Care Nurse - Full Time Days
Posted 3 days ago
Job Viewed
Job Description
POSITION SUMMARY
The Transitional Care nurse (TCN) will ensure the coordination and continuity of healthcare as patients transition between different locations or levels of care. The TCN will assist with complex patients, focus on high hospital utilizers, chronically ill and educate patients and family caregivers to determine the root cause to poor health outcomes that may lead to readmission to the hospital. The TCN will work with the Manager of Case Management, Care Managers and hospitalists to determine a safe discharge plan and ensure patient's continuity of care upon discharge.
ESSENTIAL DUTIES AND RESPONSIBILITIES
* Responsible for post discharge contact on a case-by-case concern with Medicare, other payers, and other identified complex patients, observation and inpatient, to determine that a safe discharge plan has been fully implemented.
* Works with the Manager of Post-Acute Services Care Networks, Care Management Manager, Social Work and other members of the CM team to identify patients requiring follow up assessments and identification of criteria for patients requiring follow up phone calls or other contact.
* Assess identified cases and utilize the information and available benefits/resources to assist the patient, family/caregiver and provider.
* Document all activities specific to interventions for patients contacted in the electronic medical record.
* Coordinates services in an effort to provide integrated health services for each patient and provide benefit and health information to each patient so they are able to make informed health decisions.
* Assesses patient needs and make referral to any needed follow up services such as but not limited to MLKCH PDC, community resources, primary care provider, disease management, or other services.
* Promote the mission and core values of MLKCH.
* Document each call with all pertinent information along with interventions performed in a call log.
* Acts as a consultant for the Transitional Care Navigator Lead or other members of the CM team.
* Participates in performance improvement projects, initiatives and performs data collection for measurement of projects as assigned.
* Works closely with Post-Acute Services to ensure that patients in settings other than home are appropriately placed post recuperative.
* Has authority to add or extend services as needed to prevent readmission to MLKCH.
* May participate in interdisciplinary discharge planning teams to ensure smooth transition from inpatient to outpatient services.
* Meets regularly with CM Leadership & Post-Acute Network Manager to identify opportunities or trends to improve patient care.
* Acts as CM with any recently acquired insurance; communicates and educates patient and family as needed in obtaining assistance from PCP or PDC.
* Must utilize Translator assistance devices as needed to improve communications with patients and families.
* Work with management to identify and vet potential post-acute service providers, as well as complete site visits to skilled nursing facilities with management to ensure MLK funded patients are receiving all necessary post-acute services.
* Perform other duties as assigned.
POSITION REQUIREMENTS
A. Education
* BSN required.
* CCM or ACM certification within 2 years of hire.
B. Qualifications/Experience
* Three (3) years of experience in Care Management either acute care or telephonic Care Management/Disease Management.
* Current California Nursing license.
* Current Basic Life Support (BLS) for Health Care Providers from the American Heart Association.
* Valid unrestricted CA Driver's License and valid proof of vehicle insurance.
* Prior case management experience in an acute care setting, medical office or health advice RN preferred.
* Bi-lingual Spanish preferred.
C. Special Skills/Knowledge
* Proficient to expert computer skills utilizing Microsoft Office especially Word and Excel
* Must be customer service driven and be resourceful while utilizing high level of critical thinking skills.
* A team player that can follow a system and protocol to achieve a common goal
* Highly organized and well developed oral and written communication, problem-solving, and decision-making skills.
#LI-YD1
MLKCH Video
Pediatric Transitional Care Nurse - STAT/Float RN
Posted 16 days ago
Job Viewed
Job Description
We care for people of all ages, diagnoses, and acuity levels, giving you the chance to explore and put your skills to work. Many clients require advanced care such as tracheostomy and ventilator management. We offer paid training to prepare you for the unique and rewarding environment you will provide care in, prioritizing your skillset confidence and knowledge.
**We are looking for RNs with pediatric trach and vent experience to become a part of our High Acuity Pediatric Team to help new clients transition from hospital to home and cover critical STAT openings. We offer specialized training, 24/7 clinical support and premium pay.**
**BAYADA Offers Our RNs** :
+ One on one care
+ Flexible self-scheduling options
+ Electronic documentation
+ In-depth paid training and shadowing with award-winning simulation labs
+ Short commute times - we match you with cases near your home
+ 24/7 on call clinical support
**Available RN Shifts:**
+ 8, 10 or 12-hour shifts
+ 1st, 2nd, or 3rd shift
+ PRN, Part-Time, or Full-Time
**RN Field Benefits Include:**
+ Weekly pay every Thursday
+ PTO & sick time
+ Medical, Dental, and Vision benefits
+ Company-paid life insurance
+ Employee Assistance Program
+ Public Service Loan Forgiveness Partner
+ 401K
+ Preventive Care Coverage for ALL employees (PRN included)
Pay: $32/hr - $50/hr
**Apply now to join our team!**
NER-SJ-RX
**As an accredited, regulated, certified, and licensed home health care provider, BAYADA complies with all state/local mandates.**
BAYADA is celebrating 50 years of compassion, excellence, and reliability. Learn more about our 50th anniversary celebration and how you can join in here ( .
BAYADA Home Health Care, Inc., and its associated entities and joint venture partners, are Equal Opportunity Employers. All employment decisions are made on a non-discriminatory basis without regard to sex, race, color, age, disability, pregnancy or maternity, sexual orientation, gender identity, citizenship status, military status, or any other similarly protected status in accordance with federal, state and local laws. Hence, we strongly encourage applications from people with these identities or who are members of other marginalized communities.
Transitional Care Registered Nurse 37.5
Posted 5 days ago
Job Viewed
Job Description
Union: NYSNA
Grant Funded, 1115 Waiver
Monday- Friday
9am-5PM
Requirements:
- Current RN licensure in New York State
- Bilingual ( English & Spanish )
- 2 years of Med-Surg, ED & Community Health experience required.
- BSN required
- MSN preferred
- BLS & ACLS
Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.
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Transitional Care Registered Nurse 37.5
Posted 5 days ago
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Job Description
Union: NYSNA
Grant Funded, 1115 Waiver
Monday- Friday
9am-5PM
Requirements:
- Current RN licensure in New York State
- Bilingual ( English & Spanish )
- 2 years of Med-Surg, ED & Community Health experience required.
- BSN required
- MSN preferred
- BLS & ACLS
Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.
Transitional Care Team Nurse
Posted today
Job Viewed
Job Description
MGA Homecare has been providing Private Duty Nursing, Skilled Nursing Visits, Occupational Therapy, Physical Therapy, and Speech Therapy services within the home and community-based setting for over a decade. In 2022 MGA has opened its doors to MGA Behavior Therapy which offers Applied Behavior Analysis (ABA) and early behavior intervention for pediatric patients with autism spectrum disorder (ASD) and other developmental disabilities.
We aim to help our patients and their families by delivering high-quality clinical care in the comfort of their homes. Our goal is to make the lives of our patients and their families easier by demonstrating compassion and integrity at the heart of everything we do. By bringing individualized attention and support throughout every home. MGA Homecare is proudly serving the states of Arizona, Colorado, North Carolina, Tennessee, Texas, and Washington, and are here to be a resource for patients and their families.
Job Description
This role reports directly to the Director of Operations and is responsible for transitioning pediatric patients being discharged from the hospital to home for the first time. The position involves caring for patients across the Dallas metroplex and providing coverage until a permanent caregiver is assigned. Once a permanent caregiver is in place, the role will transition to supporting the next patient being discharged home.
- Provide nursing care and assist in transitioning patients from hospital to home.
- Assist with hospitals and agency to facilitate hospital discharge and prevent re-hospitalization.
- Assist with care coordination with patient care team.
- Provide education to patient and family caregivers as identified.
- Train new permanent nurses when identified.
- Meet the new families at the hospital and help set expectations prior to discharge.
- Help assist with office New hire training classes
- Help assist with office clinical tasks as needed
- Provide PRN nursing coverage in the Dallas metroplex area
Qualifications
- Current state license as a Registered Nurse, BSN preferred.
- Minimum of two years of nursing experience in a Home Health or Acute setting preferred.
- Trach and Vent experience
- NICU/PICU experience preferred but not required.
- Current CPR card and Current health certificate as applicable.
- Current state driver's license, reliable transportation and automobile insurance.
- Attention to detail and time management skills
- Effective problem-solving and conflict resolution
- Good organization and effective communication
Additional Information
Benefits are available to eligible employees on the first of the month after 30 days of employment and include:
- Health, Dental & Vision Coverage
- Health Savings Accounts (HSA-available if enrolled in a high deductible plan)
- Flexible Spending Accounts (FSA & LPFSA)
- Dependent Care Reimbursement Accounts (DCRA)
- Employee Assistance Program (EAP-available if enrolled in Health plan)
- 401(k) retirement plan
- Paid Time Off (PTO)
- 100% Company Paid Basic Life Insurance (if enrolled in Health plan)
- Voluntary Life Insurance
- Short & Long-Term Disability
- Critical Illness/Accident Insurance
- Hospital Indemnity Insurance
- Identity Protection Plan
- Legal Care Plan
- Pet Discount Program
All your information will be kept confidential according to EEO guidelines.
#IND456-TX-N
Dialysis Transitional Care Registered Nurse - RN
Posted today
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Job Description
**PURPOSE AND SCOPE:**
The professional registered nurse Home Therapies RN CAP 2 may be an entry level designation into the Clinical Advancement Program (CAP) for new employees who meet the RN CAP 2 criteria or attained through advancement from RN CAP 1. This position is accountable and responsible for the provision and coordination of clinically competent care including assessment, planning, intervention and evaluation for an assigned group of patients. This may include delegation of appropriate tasks to direct patient care staff including but not limited to RNs, LVN/LPNs and Patient Care Technicians. As a member of the End Stage Kidney Disease (ESKD) health care team, this position participates in decision-making, teaching, leadership functions, and quality improvement activities that enhance patient care outcomes and facility operations.
**PRINCIPAL DUTIES AND RESPONSIBILITIES:**
All duties and responsibilities are expected to be performed in accordance with Fresenius Kidney Care policy, procedures, standards of nursing practice, state and federal regulations.
+ Performs all essential functions under the direction of the Supervisor and with guidance from the Educator, Preceptor or in collaboration with another Registered Nurse.
+ Performs ongoing, systematic collection and analysis of dialysis data for assigned patients and documents in the patient medical record, makes adjustments or modifications to treatment plan as indicated and notifies Supervisor or physician as needed.
+ Assesses, collaborates and documents patient/family's basic learning needs to provide initial and ongoing education to patients and family.
+ Directs and provides, in collaboration with the patient, home care partner, direct and ancillary patient care staff, all aspects of the provision of safe and effective delivery of dialysis therapies to assigned patients.
+ Administers medications as prescribed or in accordance with approved algorithm(s), and documents appropriate medical justification and effectiveness.
+ Initiates or assists with emergency response measures.
+ Serves as a resource, leader, coach, mentor and role model for new and incumbent employees by setting examples of appropriate behavior, work habits and attitudes towards patients, co-workers, supervisors and the company at the facility and area level.
+ Ensures correct laboratory collection, processing and shipping procedures are performed and reschedules missed or insufficient laboratory collections.
+ Identifies expected outcomes, documents and updates the nursing assessment and plan of care for assigned patients through collaboration with the Interdisciplinary Team.
+ Ensures patient awareness related to transplant and treatment modality options.
+ Assists in the identification, evaluation, selection and education of Home Dialysis candidates and Home Partners.
+ Performs assessment and identifies barriers of the Home Dialysis candidate's home environment and partner/ family readiness and ability to perform dialysis treatments in the home.
+ Trains home dialysis patients and / or Home Partners on the safe, effective operation and maintenance of all Home Dialysis equipment and treatment supplies through a formal standardized Home Dialysis Training Program.
+ Participates in education and quality improvement projects at the facility and area level as directed by Supervisor.
+ May serve as a Preceptor to new employees.
+ Required to complete CAP requirements to either maintain or advance.
+ Performs all other duties as assigned by Supervisor.
**PHYSICAL DEMANDS AND WORKING CONDITIONS:**
The physical demands and work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
+ The position provides direct patient care that regularly involves heavy lifting, moving of patients and assisting with ambulation. Equipment aids and/or coworkers may provide assistance.
+ This position requires frequent, prolonged periods of standing and the employee must be able to bend over.
+ The employee may occasionally be required to move, with assistance, machines and equipment of up to 200 lbs., and may lift chemical and water solutions of up to 30 lbs. as high as 5 feet.
+ The work environment is characteristic of a health care facility with air temperature control and moderate noise levels.
+ May be exposed to infectious and contagious diseases/materials.
+ Rotates coverage with other licensed home therapy staff as assigned to ensure reliable and adequate coverage.
+ Position requires participation in on-call rotation, night, weekend, holiday or as defined by individual program needs.
+ The position may require travel to training sites, other facilities and patient homes.
+ May be asked to provide essential functions of this position in other locations including patient's home with the same physical demands and working conditions as described above.
+ Day to day work includes desk work, computer work, interaction with patients, facility/hospital staff and physicians.
**SUPERVISION:**
Assigned oversight of RNs, LPNs/LVNs, Patient Care Technicians and Home Therapies Care Team Assistants as a Team Leader or designated Nurse in Charge, after meeting all the following:
+ Successful completion of all FKC education and training requirements for new employees.
+ Must have a minimum of 3 months experience home dialysis therapies as a RN.
**EDUCATION and LICENSURE:**
+ Graduate of an accredited School of Nursing.
+ Current appropriate state licensure.
+ Current or successful completion of CPR BLS Certification
+ Must meet the practice requirements in the state in which he or she is employed.
**EXPERIENCE AND REQUIRED SKILLS:**
+ Entry level for RNs with a minimum of 2 years or more of Nephrology Nursing experience within the last 2 years as a RN.
**EO/AA Employer: Minorities/Females/Veterans/Disability/Sexual Orientation/Gender Identity**
**Fresenius Medical Care North America maintains a drug-free workplace in accordance with applicable federal and state laws.**
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**EOE, disability/veterans**