387,075 Transitional Care Nurse jobs in the United States

Overview
Carle Health is seeking a Nurse Practitioner to join our Transitional Care Clinic (TCC) at Carle Foundation Hospital in Urbana, Illinois.
Opportunity Details
+ Typical schedule 10 hour/ 4 days per week
+ Provides health assessment for patients directed toward returning to a state of wellness, establishing the need for intervention, evaluating responses to and outcomes of therapy, and following a mutually agreed upon treatment plan.
+ Ensures documentation of care is complete and accurate.
+ Communicates with other health professionals, families, and referral agencies regarding health status and needs of particular patients or patient groups.
+ Serves as a role model in the enhancement of nursing practice and professional conduct following professional practice guidelines. Responsible for nursing care delivery by patient care support staff.
+ Perform assessments on patients referred to the TCC and determine eligibility for the program.
+ Place orders for scheduling patients in the TCC.
+ Complete full assessments and provide ongoing patient care and management while the patient is under the responsibility of the Transitional Care Clinic.
+ Place appropriate follow-up orders for patients evaluated in the TCC.
+ Monitor patient improvement and response to therapy over the 30-day post-hospital period.
+ Coordinate return of the patient responsibility to their Primary Care Provider
+ Case management
+ Home visits for appropriate TCC patients within 60 mile radius
**Education Requirements:**
+ Master's Degree in Nursing
+ Two years of experience as an APN in a primary care clinic or hospital setting preferred
**Licensure/Certification Requirements:**
+ Current Illinois registered nurse license and advanced practice nurse licensure
+ Basic Life Support (BLS) and APN National Certification
About Our Community
Champaign-Urbana has been defined as a micro-urban community, meaning we have many of the amenities of a much bigger city, with the feel of a smaller town. Almost equidistant to Chicago, St. Louis and Indianapolis for fun weekends away, the area offers excellent schools, a great downtown scene, the University of Illinois, Big 10 sports and an exciting college town atmosphere, including Krannert Center for the Performing Arts.
About Us
Find it here.
Discover the job, the career, the purpose you were meant for. The supportive and inclusive team where you can thrive. The place where growth meets balance - and opportunities meet flexibility. Find it all at Carle Health.
Based in Urbana, IL, Carle Health is a healthcare system with nearly 16,600 team members in its eight hospitals, physician groups and a variety of healthcare businesses. Carle BroMenn Medical Center, Carle Foundation Hospital, Carle Health Methodist Hospital, Carle Health Proctor Hospital, Carle Health Pekin Hospital, and Carle Hoopeston Regional Health Center hold Magnet® designations, the nation's highest honor for nursing care. The system includes Methodist College and Carle Illinois College of Medicine, the world's first engineering-based medical school, and Health Alliance. We offer opportunities in several communities throughout central Illinois with potential for growth and life-long careers at Carle Health.
We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization. | For more information:
Compensation and Benefits
The compensation range for this position is $55.13-$71.67/hour. This represents a good faith minimum and maximum range for the role at the time of posting by Carle Health. The actual compensation offered a candidate will be dependent on a variety of factors including, but not limited to, the candidate's experience, qualifications, location, training, licenses, shifts worked and compensation model. Carle Health offers a comprehensive benefits package for team members and providers. To learn more visit careers.carlehealth.org/benefits

**Job Type:** Regular
**Time Type:** Full time
**Work Shift:** Day (United States of America)
**FLSA Status:** Exempt
**When you join the growing BILH team, you're not just taking a job, you're making a difference in people's lives.**
Beth Israel Lahey Health and Primary Care are devoted to consistently promoting a culture of Wellbeing, Empathy, Collaboration, Accountability, Respect, and Equity as outlined in our organization's WE CARE values which can be reviewed here {insert hyperlink}.
In this role, you will oversee the Primary Care Central Transitional Care Management (TCM) team of nurses, with responsibility for ensuring effective management of the TCM process. Reporting to the Primary Care Director of Nursing, with dotted line reporting to a Director of Operations, this role is essential in sustaining the culture and productivity of this centralized team for all Primary Care.
**Job Description:**
ESSENTIAL DUTIES & RESPONSIBILITIES (including but not limited to):
Directly manages all central TCM nurses and acts as the primary liaison between the TCM team and stakeholders (CMO, Nursing Director, Regional Ops, Practice Managers, Analytics, HR).
Represents the TCM team in leadership, organizational, and EPIC-related meetings and action plans to ensure alignment with system goals and adherence to performance outcomes.
Conduct regular 1:1 check-ins and annual performance reviews.
Oversee onboarding, orientation, ongoing training, and compliance for TCM staff.
Manage recruitment and hiring in collaboration with HR.
Lead collaboration and communication with regional ops and practices regarding TCM workflows and case updates.
Maintains knowledge of daily operating procedures to maintain an ability to cover outages on the team or ad hoc call coverage, as needed
QUALIFICATIONS:
Active Massachusetts Registered Nursing License required
Minimum 3 years Primary Care Nursing experience preferred
Team Leadership/management experience preferred
OTHER REQUIREMENTS:
Consistently promote a culture of Wellbeing, Empathy, Collaboration, Accountability, Respect, and Equity as outlined in the organization's WE CARE values.
Demonstrated commitment and actions to valuing diversity and contributing to an inclusive working and learning environment
Must be able to travel to designated central team locations, as needed, to support TCM team and daily work
ABOUT US
Beth Israel Lahey Health (BILH) places great value on being a diverse and inclusive community. BILH and the Department of {insert hiring department} are dedicated to diversity, equity, and inclusion as we aim to reflect the diversity of the patients in the communities that we serve. We believe in equal access to quality care, as well as employment and advancement opportunities encompassing the full spectrum or human diversity: race, gender, sexual orientation, religion, ethnicity, national origin and all the other forms of group and individual identity and expression that make us better able to provide innovative and cutting-edge healthcare and research.
**As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) as a condition of employment.**
**More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.**
**Equal Opportunity** **Employer/Veterans/Disabled**

Job Type

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

**Come for the Flexibility,** Stay for the Culture ( Home Health Care was founded on the principle that health care gets better when clients get better care at home-the place they most want to be. Delivering care is our highest priority and greatest joy.
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.

Job Description

Seeking a Transitional Care Nurse Practitioner to deliver high-touch, high-quality care to high-risk patients within their homes in the Rockford, IL area.

Details/Responsibilities:

• Full-time, Mon - Fri, 8am-5pm
• Deliver high-touch, high-quality care to the highest risk patients within their homes
• This role is supported by a scribe/medical assistant, nurse, social worker, and other resources.
• NPs make 6-7 visits daily in a defined territory and collaborate continuously with other team members for care coordination and all other needs.
• APPs in a defined territory collaborate continuously with other team members for post-discharge follow up care coordination, medication reconciliation, and social services follow up.
• Provide post-discharge support according to defined pathways within the patient's home
• Develop care plans and individualize goals of care with patient, their families, and their providers
• Optimize and monitor clinical status, identify and address gaps in care, reconcile medications and address adherence challenges
• Collaborate with Transitional Care Managers, home health, social workers, hospitals, SNFs, and specialists
• Structure and prioritize scheduling based on clinical complexity for both new and routine patients
• Recognize, diagnose, and manage both acute and chronic medical conditions in order to prevent destabilization and readmissions
• Provide after-hours and weekend call support, shared with other in state providers
• Facilitate and conduct goals of care and advance care planning discussions with patients and families
• Assess and evaluate family / caregiver needs and limitations
• Teach patients, caregivers, and others about their health conditions
• Accurate and timely documentation of patient encounters in electronic medical records
• Champion compliance and dissemination of policy, including HIPAA, Patient Identification, and Incident Reporting
• Other duties, as assigned

Qualifications:

• Have an active, non-probationary state medical license, including US work authorization, if applicable
• 1+ years APN experience, preferably with a Medicare population
• Experience in home-based care (as RN or APP) preferred
• Flexibility to travel throughout service area
• Electronic Medical Record experience
• Computer skills: Ability to quickly navigate and use multiple computer programs to include, but not limited to: Gmail, MS Word or Google Docs, Excel or Google Sheets, etc.
• Additional language proficiency in Spanish, Polish, Russian, or other languages spoken within the communities we serve preferred but not required

Compensation & Benefits:

• Competitive Salary
• Tuition reimbursement
• Employee stock purchase plan
• Health insurance
• 401(k) matching
• Paid time off
• Vision insurance
• Dental insurance
• Family leave
• Flexible spending account
• Flexible schedule

The Community:

Nestled along a scenic river in northern Illinois, this city offers a unique blend of affordability, cultural charm, and natural beauty, making it an ideal place to live, work, and explore. Residents enjoy access to expansive parks, botanical gardens, a vibrant arts scene, and family-friendly attractions-all without the high cost or congestion of larger urban centers. The area features a strong sense of community, diverse neighborhoods, and easy living, with a variety of local shops, restaurants, and entertainment options. Conveniently located about 90 miles from Chicago and 70 miles from Madison, it provides quick access to major metro areas while maintaining its own identity and pace. Whether you're looking to raise a family, start a career, or enjoy a more relaxed lifestyle with city perks nearby, this region offers a welcoming and well-rounded home base.

APPLY NOW or TEXT Job #CMW and email address to 636 - 628 - 2412.

Search all of our provider opportunities at: brittmedical DOT com

Job Description

Seeking a Transitional Care Nurse Practitioner to deliver high-touch, high-quality care to high-risk patients within their homes in the Allentown, PA area.

Details/Responsibilities:

• Full-time, Mon - Fri, 8am-5pm
• Deliver high-touch, high-quality care to the highest risk patients within their homes
• This role is supported by a scribe/medical assistant, nurse, social worker, and other resources.
• NPs make 6-7 visits daily in a defined territory and collaborate continuously with other team members for care coordination and all other needs.
• APPs in a defined territory collaborate continuously with other team members for post-discharge follow up care coordination, medication reconciliation, and social services follow up.
• Provide post-discharge support according to defined pathways within the patient's home
• Develop care plans and individualize goals of care with patient, their families, and their providers
• Optimize and monitor clinical status, identify and address gaps in care, reconcile medications and address adherence challenges
• Collaborate with Transitional Care Managers, home health, social workers, hospitals, SNFs, and specialists
• Structure and prioritize scheduling based on clinical complexity for both new and routine patients
• Recognize, diagnose, and manage both acute and chronic medical conditions in order to prevent destabilization and readmissions
• Provide after-hours and weekend call support, shared with other in state providers
• Facilitate and conduct goals of care and advance care planning discussions with patients and families
• Assess and evaluate family / caregiver needs and limitations
• Teach patients, caregivers, and others about their health conditions
• Accurate and timely documentation of patient encounters in electronic medical records
• Champion compliance and dissemination of policy, including HIPAA, Patient Identification, and Incident Reporting
• Other duties, as assigned

Qualifications:

• Have an active, non-probationary state medical license, including US work authorization, if applicable
• 1+ years APN experience, preferably with a Medicare population
• Experience in home-based care (as RN or APP) preferred
• Flexibility to travel throughout service area
• Electronic Medical Record experience
• Computer skills: Ability to quickly navigate and use multiple computer programs to include, but not limited to: Gmail, MS Word or Google Docs, Excel or Google Sheets, etc.
• Additional language proficiency in Spanish, Polish, Russian, or other languages spoken within the communities we serve preferred but not required

Compensation & Benefits:

• Competitive Salary
• Paid vacation, sick time, and investment/retirement 401K match options
• Health insurance, vision, and dental benefits
• Opportunities for leadership development and continuing education stipends
• New centers and flexible work environments
• Opportunities for high levels of responsibility and rapid advancement

The Community:

Experience the perfect blend of peaceful living and vibrant community life in a region where rolling hills meet revitalized downtowns, and affordability goes hand-in-hand with opportunity. This area offers a welcoming, family-friendly atmosphere with excellent schools, diverse dining, and a growing arts and culture scene. Residents enjoy access to scenic parks, hiking trails, and local festivals, as well as a strong job market in healthcare, manufacturing, education, and logistics. With easy highway access to major cities like Philadelphia and New York, it's an ideal location for those seeking a balanced lifestyle-where small-town comfort meets big-city convenience.

APPLY NOW or TEXT Job #CMW and email address to 636 - 628 - 2412.

Search all of our provider opportunities at: brittmedical DOT com

The Transitional Care Nurse works as a part of the interdisciplinary team, as well as with community agencies, to ensure post-discharge collaboration in meeting patient's needs as determined by the social determinants of health screening. The TCN ensures that comprehensive care in the community is available for the patient in the post-hospital discharge period, with the goal of preventing readmission.

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.

The Transitional Care Nurse works as a part of the interdisciplinary team, as well as with community agencies, to ensure post-discharge collaboration in meeting patient's needs as determined by the social determinants of health screening. The TCN ensures that comprehensive care in the community is available for the patient in the post-hospital discharge period, with the goal of preventing readmission.

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.

In collaboration with the patient/family, physicians, and the interdisciplinary team, the Transitional Care Nurse Navigator facilitates the patient's progress through the acute episode of care in an efficient and cost effective manner and creates a plan along with patient/family and providers for transition from inpatient setting to post-acute setting. Initiates evidence based protocols and order sets according to the patients admission diagnosis, influencing the progression of care, facilitating the patients' navigation through the acute care episode, and proposes an appropriate transition plan within 48 hours of admission. The Transitional Care Nurse Navigator serves as an advocate for the patient and family throughout the entire care continuum and facilitates communication with the multidisciplinary team, referring physician and ambulatory care team. Fosters patient/family self-management and compliance with individualized plan of care via post-acute phone call.

Education

Bachelors Degree : BSN (Required)

Experience

3 Years experience in nursing in an acute care setting. (Required)

Previous experience in a clinical healthcare setting or insurance setting responsible for direct management of patient care; including planning, coordination, discharge planning and delivery of needed services. (Preferred)

License/Certifications

RN-LIC - PA Registered Nurse License (Required)

CCM - Certified Case Manager (Preferred)

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