RN Care Transitions Coach - Discharge & Readmission

Jobtome; Fitchburg (MA); On-site; USD 42,000 - 82,000; Full time

Benefits offered by this job

Competitive benefits

Job summary

Jobtome is seeking an experienced registered nurse to provide care transition support for members from hospital admission through a 30-day post-discharge program. You will coordinate with discharge planners, hospital staff, and family to ensure safe transitions and reduce readmissions.

The role involves post-discharge home visits for high-risk members, education on transition pillars, and collaboration with interdisciplinary teams.

Qualifications

• 2+ years experience in health care
• 1 year in hospital discharge planning or care management or behavioral health setting
• RN license active and unrestricted
• Valid driver’s license and reliable transportation
• Knowledge of Care Transitions Intervention (CTI) or similar model
• Background in discharge planning and/or home health
• Able to work independently with minimal supervision
• Excellent communication and problem-solving skills
• Proficient in Microsoft Office and related software

Responsibilities

• Provide care transition support from hospital admission through 30-day post-discharge program
• Collaborate with discharge planners, hospitalists, providers, facility staff and families
• Ensure safe transitions with adequate caregiving and medical oversight
• Coordinate with ancillary providers and community services for safe transition
• Conduct face-to-face hospital visits and post-discharge home visits for high-risk members
• Reassess member needs using Coleman Care Transition model
• Educate members on transition pillars and follow-up care
• Engage ICT meetings and collaborate with interdisciplinary teams
• Communicate recommendations to non-behavioral health care managers
• Travel 40-50% locally as required

Skills

RN

Time management

Verbal & written communication

Self-motivation

Proactive and detail-oriented

Microsoft Office

Education

RN license (active)

Tools

Microsoft Office

Job description

Jobtome is seeking an experienced registered nurse to provide care transition support for members from hospital admission through a 30-day post-discharge program. You will coordinate with discharge planners, hospital staff, and family to ensure safe transitions and reduce readmissions.

The role involves post-discharge home visits for high-risk members, education on transition pillars, and collaboration with interdisciplinary teams.