Home Health Virtual Care RN

Accompany Health, Inc.; Lansing (MI); Remote; USD 70,000 - 100,000; Full time

Job summary

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

The role focuses on safe, coordinated transitions across care settings, helping patients avoid readmissions and stay engaged with high-quality home-based care. You will work with a multidisciplinary team to deliver virtual and telephonic nursing visits, coordinating with hospitals and community providers while

Qualifications

• Active RN license in state of employment and willingness to obtain additional licensure.
• 2+ years of experience providing care to adult/geriatric patients with complex chronic medical conditions.
• Experience in transitions of care, including post-discharge follow-up, medication reconciliation, and care coordination.
• Strong clinical assessment, critical thinking, and care coordination skills.
• Comfort working within interdisciplinary care teams, including clinical and non-clinical partners.

Responsibilities

• Provide post-discharge transitions of care support to reduce readmissions and ED revisits.
• Perform clinical assessments, identify red flags, escalate to urgent care when needed.
• Ensure accurate medication reconciliation post-discharge and adherence to plan.
• Provide patient education, coaching and self-management support.
• Coordinate with hospitals and community providers to support safe discharge planning.

Skills

Care coordination

Clinical assessment

Remote work

Telehealth

Interdisciplinary teamwork

EMR proficiency

Education

RN license

Tools

EMR systems

Job description

Accompany Health is on a mission to give patients with complex needs the dignified, high-quality care they deserve but rarely receive. A primary, behavioral, and social care provider, Accompany Health walks alongside patients for their entire care journey, offering at-home and virtual care, as well as 24/7 support. Partnering with innovative payors, Accompany Health is powered by remarkable care teams, elegant technology, and a commitment to evidence-based practice. We build long-term relationships with our patients so they know, without question, that our team is here for them day or night, year after year. We focus on the health outcomes most important to our patients to make it clear that they lead the way. To achieve our mission, we collaborate with community-based organizations, local providers, and health plans. Led by our empathetic care teams, guided by proven care models, and powered by our own technology, we deliver a level of service that our communities rightfully deserve but rarely receive. While our headquarters is in Bethesda, MD, our teams are distributed across the country. If you're eager to make a tangible difference in people's lives, to help correct long-standing disparities in health care, join us.

As the Registered Nurse, Care Transitions, you will be at the forefront of delivering seamless, high-impact care for patients with complex medical, behavioral health, and social needs. In this pivotal role, you will champion safe, coordinated transitions across care settings—helping patients stay healthy at home, reduce avoidable hospitalizations, and experience truly continuous, high-quality care. You will serve as a vital connector between post-acute transitions and ongoing, integrated nursing support, ensuring patients feel supported, informed, and empowered every step of the way. You'll join a collaborative, mission-driven multidisciplinary team that includes Physicians, Advanced Practice Clinicians, Health Advocates, Social Workers, Behavioral Health Clinicians, Psychiatrists, Pharmacists, and Patient Experience Navigators. Working closely with both local and centralized teams, you'll deliver patient-centered care through a blend of virtual and telephonic services tailored to meet each patient's unique needs. As our innovative care model continues to grow and evolve, this role offers the opportunity to grow with it, helping shape the future of integrated, home-based care.

Responsibilities

• Provide post-discharge transitions of care support in order to reduce readmissions, rehospitalizations and ED revisits for patients recently discharged from emergency departments, hospitals, skilled nursing facilities, or behavioral health facilities. Completing a RN visit and/or interaction within 7 days of discharge
• Performing clinical assessments, identifying red flags, and appropriately escalating to urgent care and/or supervising physicians when needed for patients at risk of decompensation and/or readmission
• Ensuring accurate medication reconciliation post-discharge, with appropriate medications in-hand and adherence to medication plan
• Providing appropriate patient education, coaching and self-management support
• Identifying clinical, behavioral, and social barriers to recovery or stability and coordinate appropriate follow-up care and referrals
• Providing patient remote monitoring support when needed to ensure recovery and prevent decompensation
• Support proactive and longitudinal interactions for high-risk patients with frequent utilization to prevent avoidable inpatient and emergency department visits
• Conduct virtual (video, phone, text) nursing visits and interactions based on patient acuity, program needs, and care plans
• Collaborate closely with interdisciplinary care team members to ensure continuity of care aligned with patient goals and values
• Coordinate with external partners, including hospitals and community providers, to support safe discharge planning and reduce readmissions
• Maintain timely, accurate clinical documentation in the electronic medical record
• Utilize electronic data tools and dashboards to prioritize work, manage patient outreach, and monitor care outcomes
• Participate in triage and care transitions coverage as needed across markets, including holiday coverage per policy
• Participate in quality improvement initiatives and provide feedback on workflows and program design
• Participate in team meetings, trainings, and occasional in-person team-building activities
• Comfort operating across care settings and adjusting between virtual, in-home, and transitional care workflows
• Excitement about contributing to an evolving, innovative, value-based care model

Qualifications

• Active Registered Nurse (RN) license in state of employment and willingness to obtain additional licensure as requested
• 2+ years of experience providing care to adult and/or geriatric patients with complex chronic medical conditions
• Demonstrated experience in transitions of care, including post-discharge follow-up, medication reconciliation, and care coordination
• Strong clinical assessment, critical thinking, and care coordination skills
• Comfort working within interdisciplinary care teams, including clinical and non-clinical partners
• Proficiency with electronic medical records and technology-enabled care delivery
• Strong skills in remote work, virtual communication, and prioritization to manage competing demands
• Experience with virtual care, both telephonic and video
• Experience in home-based care, geriatrics, internal medicine, family medicine, palliative care, or value-based care organizations
• Experience in trauma-informed care
• Experience participating in quality improvement initiatives
• Multi-state RN licensure in at least one of the following states: MI, CO & MA (must be willing to obtain additional licenses - support and reimbursement provided)

Salary ranges are based on role, level, and location, and reflect the minimum to maximum target for new hire pay in each position. Depending on the role, you may also be eligible for bonus, equity, and benefits. Where you fall within the range depends on factors such as your location, skills, experience, and relevant education or training.