Care Transition Nurse

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