RN Transitional Care Navigator – Reduce Readmissions

01 Salinas Valley Health Medical Center; Salinas (CA); On-site; USD 207,598,809 - 234,192,000; Full time

Job summary

01 Salinas Valley Health Medical Center is seeking a Transitional Care Coordinator to ensure smooth transitions for discharged patients. The role involves coordinating with physicians, social workers, and families to reduce readmissions and improve outcomes.

The TCC will follow a patient‑centered plan across home programs and clinic settings, providing education, monitoring, and timely follow‑ups for up to 30 days post discharge.

Qualifications

• Associate degree in nursing required; BSN preferred.
• Current California RN license required; BLS required.
• Three (3) years of nursing experience required; knowledge of post‑acute care coordination and case management principles.

Responsibilities

• Assess, evaluate, and implement a plan of care with physicians, hospital teams, and families.
• Develop a Continuum of Care plan with leadership, social work, and case management.
• Follow up with patients to ensure adherence to medical treatment plans.
• Meet eligible patients in the transition program, including virtual home program patients, as needed.
• Identify barriers and needs to outpatient care and support.
• Call patients within 24–48 hours post discharge to identify barriers and coordinate resources.
• Provide daily phone or video follow‑ups for virtual patients during the program.
• Triages patients using clinical judgment for urgent care or ER referral.
• Serve as a resource and educator for patients and families for 30 days post discharge.
• Intervene to reduce avoidable ER visits and readmissions.
• Provide disease‑specific education through in‑person, telephonic, or virtual means.
• Monitor vital signs and educate on equipment use and schedules.
• Document all interactions and care plans in the EHR.
• Facilitate follow‑up appointments with PCPs and specialists.
• Collaborate with leadership to address barriers as needed.

Skills

Bilingual Spanish

Case management

Electronic Health Records

Education

Associate degree in nursing

BSN preferred

Tools

EHR system

Job description

01 Salinas Valley Health Medical Center is seeking a Transitional Care Coordinator to ensure smooth transitions for discharged patients. The role involves coordinating with physicians, social workers, and families to reduce readmissions and improve outcomes.

The TCC will follow a patient‑centered plan across home programs and clinic settings, providing education, monitoring, and timely follow‑ups for up to 30 days post discharge.