Remote RN: Care Transitions & At-Home Health

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, 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