Care Transitions RN - Home & Virtual Care

Accompany Health, Inc.; Oregon; Hybrid; USD 85,000 - 110,000; Full time

Job summary

Accompany Health, Inc. is seeking a Registered Nurse, Care Transitions, to lead seamless, high-impact care for patients with complex medical, behavioral health, and social needs.

You will work across home-based and telephonic services to ensure safe, coordinated transitions. You will perform post-discharge visits within 7 days, conduct medication reconciliation, support follow-up visits, educate patients, and collaborate with an interdisciplinary team to reduce readmissions.

Qualifications

• Active RN license in state of employment.
• 2+ years of experience providing care to adult/geriatric patients with complex chronic conditions.
• Demonstrated experience in transitions of care, including post-discharge follow-up, medication reconciliation, and care coordination.

Responsibilities

• Provide post-discharge transitions of care support to reduce readmissions and ED revisits.
• Complete an RN visit within 7 days of discharge.
• Perform clinical assessments and escalate when needed.
• Ensure accurate post-discharge medication reconciliation and adherence.
• Schedule post-discharge AH provider visit within 7 days of discharge.
• Educate patients and provide self-management support.
• Identify barriers to recovery and coordinate follow-up care.
• Provide remote monitoring to support recovery and prevent decompensation.
• Conduct virtual nursing visits and collaborate with the care team.
• Coordinate with hospitals and community providers for safe discharge planning.
• Maintain timely clinical documentation in the EMR and use data tools to prioritize work.
• Participate in triage and coverage across markets.

Skills

RN license

Transitions of care

Care coordination

Post-discharge follow-up

Medication reconciliation

Job description

Accompany Health, Inc. is seeking a Registered Nurse, Care Transitions, to lead seamless, high-impact care for patients with complex medical, behavioral health, and social needs.

You will work across home-based and telephonic services to ensure safe, coordinated transitions. You will perform post-discharge visits within 7 days, conduct medication reconciliation, support follow-up visits, educate patients, and collaborate with an interdisciplinary team to reduce readmissions.