RN, Care Transitions — At-Home & Virtual Care

Accompany Health, Inc.; Bethesda (MD); Remote; USD 55.000 - 62.000; Vollzeit

Zusammenfassung

Accompany Health, Inc. is seeking a Registered Nurse, Care Transitions, to lead safe, coordinated post-discharge care for adults with complex needs. This role blends at-home and telephonic visits to reduce readmissions and support patients across the care continuum.

You will work with an interdisciplinary team and external partners to ensure accurate medication reconciliation, timely follow-ups, and patient education. Remote work across markets offers ongoing professional growth.

Qualifikationen

• Active RN license in state of employment.
• 2+ years of experience providing care to adult and/or geriatric patients with complex chronic 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.
• Experience delivering patient education and supporting chronic disease self-management.
• 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.

Aufgaben

• Provide post-discharge transitions of care support to reduce readmissions, rehospitalizations and ED revisits for patients recently discharged from emergency departments, hospitals, skilled nursing facilities, or behavioral health facilities.
• Complete an RN visit and/or interaction within 7 days of discharge.
• Perform clinical assessments, identify red flags, and escalate when needed.
• Ensure accurate medication reconciliation post-discharge with adherence to the plan.
• Schedule and ensure completion of post-discharge visits within 7 days of discharge date.
• Provide patient education, coaching and self-management support.
• Identify barriers to recovery and coordinate follow-up care and referrals.
• Provide remote monitoring support as needed to prevent decompensation.
• Collaborate with interdisciplinary team to ensure continuity of care.

Kenntnisse

Transitions of care

Care coordination

Remote work

Interdisciplinary collaboration

Patient education

Ausbildung

Active RN license

Jobbeschreibung

Accompany Health, Inc. is seeking a Registered Nurse, Care Transitions, to lead safe, coordinated post-discharge care for adults with complex needs. This role blends at-home and telephonic visits to reduce readmissions and support patients across the care continuum.

You will work with an interdisciplinary team and external partners to ensure accurate medication reconciliation, timely follow-ups, and patient education. Remote work across markets offers ongoing professional growth.