RN, Care Transitions: At-Home & Virtual Care

Accompany Health, Inc.; United States; Remote; USD 55,000 - 62,000; Full time

Job summary

Accompany Health is hiring an experienced Registered Nurse for Care Transitions to support patients with complex medical, behavioral health, and social needs. You will coordinate safe, timely post-discharge care and work across teams to prevent readmissions while empowering patients at home.

In this role, you will conduct timely RN visits, perform medication reconciliation, and educate patients and families on self-management.

Qualifications

• Active RN license in state of employment.
• 2+ years of experience with adult/geriatric patients with complex chronic conditions.
• Experience in transitions of care, post-discharge follow-up, medication reconciliation, and care coordination.
• Strong clinical assessment, critical thinking, and care coordination skills.
• Experience with remote work, virtual communication, and prioritization.
• Multi-state RN licensure in MI, CO & MA (willing to obtain additional licenses).

Responsibilities

• Provide post-discharge transitions of care to reduce readmissions.
• Complete an RN visit/interactions within 7 days of discharge.
• Perform clinical assessments and escalate when needed.
• Ensure medication reconciliation post-discharge.
• Schedule post-discharge visits within 7 days of discharge date.
• Provide patient education, coaching and self-management support.
• Coordinate with hospitals and community providers for safe discharge.
• Maintain timely clinical documentation in the EMR.
• Utilize data tools to prioritize work and monitor outcomes.
• Participate in triage and care transitions coverage across markets.

Skills

Clinical assessment

Care coordination

Patient education

Remote work

Critical thinking

Job description

Accompany Health is hiring an experienced Registered Nurse for Care Transitions to support patients with complex medical, behavioral health, and social needs. You will coordinate safe, timely post-discharge care and work across teams to prevent readmissions while empowering patients at home.

In this role, you will conduct timely RN visits, perform medication reconciliation, and educate patients and families on self-management.