RN, Care Transitions — Home-Based & Virtual Care

Accompany Health, Inc.; Lansing (MI); Remote; USD 55,000 - 62,000; Full time

Job summary

Accompany Health, Inc. is seeking an experienced Registered Nurse for Care Transitions. You will lead post-discharge transitions to ensure safe, coordinated care, reduce readmissions, and support patients staying healthy at home.

You will collaborate with a multidisciplinary team delivering virtual and telephonic services, empowering patients and families along the care journey. You will work across markets with flexible scheduling and a focus on high-quality, patient-centered outcomes.

Qualifications

• Active RN license in state of employment.
• 2+ years 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.
• 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.

Responsibilities

• Provide post-discharge transitions of care support to reduce readmissions, rehospitalizations and ED revisits.
• Perform RN visits and interactions within 7 days of discharge where applicable.
• Conduct virtual nursing visits and interactions based on patient needs and care plans.
• Coordinate with hospitals and community providers to support safe discharge planning.
• Maintain timely, accurate clinical documentation in the EMR and monitor care outcomes.
• Participate in triage and care transitions coverage across markets as needed.

Skills

Active RN license

2+ years experience

Transitions of care

Medication reconciliation

Care coordination

Electronic medical records

Remote work

Interdisciplinary teamwork

Tools

EMR systems

Job description

Accompany Health, Inc. is seeking an experienced Registered Nurse for Care Transitions. You will lead post-discharge transitions to ensure safe, coordinated care, reduce readmissions, and support patients staying healthy at home.

You will collaborate with a multidisciplinary team delivering virtual and telephonic services, empowering patients and families along the care journey. You will work across markets with flexible scheduling and a focus on high-quality, patient-centered outcomes.