RN Transitions Specialist for Post-Discharge Care

Southeast Permanente Medical Group; Atlanta (GA); On-site; USD 75,000 - 105,000; Full time

Benefits offered by this job

Competitive pay

Medical and dental insurance

401(k) plan with employer match

Generous PTO

Job summary

Southeast Permanente Medical Group is seeking a Transitions Coach (RN) in Georgia to coordinate care for high‑risk members transitioning from acute care to community settings. You will collaborate with hospitalists, IQM/QRM staff, and other providers to ensure safe, effective discharge planning and follow-up up to 30 days post-discharge.

Responsibilities include comprehensive intake assessments, development of individualized care plans, proactive post-discharge interventions, and ongoing

Qualifications

• Unrestricted current RN licensure in the state of Georgia required or documentation to show intent to seek license.
• BS in Nursing strongly preferred
• Case Management Certification
• Care Coordination and Transition Management Course Completion/Certification.
• Valid Georgia Driver’s license.

Responsibilities

• Review referrals to Transition Coach Program within designated timeframe and evaluate Activation Assessment priority.
• Conduct thorough face-to-face assessment of member's physical, psychosocial, environmental, financial, and health status.
• Develop an individual plan of care with KP Hospitalists and other practitioners that identifies goals to be accomplished within 30 days post-discharge.
• Implement the post-discharge plan and interventions upon agreement, possibly before discharge.
• Complete home visits or telephonic outreach within 72 hours post-discharge and reassess status.
• Communicate plan to Primary and/or Specialty Care providers and schedule follow-up appointments.
• Maintain minimum weekly follow-up to monitor status and progress toward goals.
• Refer to other KP programs if outcomes are not met within 30 days, e.g., disease management or Palliative Care.
• Document all coaching interactions in Health Connect per guidelines.
• Reassess and reinforce patient self-management, including symptom and medication management.
• Arrange, coordinate, and facilitate appointments as needed.
• Identify need for discharge from Transition Coach Program and complete discharge process.

Education

RN licensure in GA

BS in Nursing

Case Management Certification

Care Coordination and Transition Management Course

Job description

Southeast Permanente Medical Group is seeking a Transitions Coach (RN) in Georgia to coordinate care for high‑risk members transitioning from acute care to community settings. You will collaborate with hospitalists, IQM/QRM staff, and other providers to ensure safe, effective discharge planning and follow-up up to 30 days post-discharge.

Responsibilities include comprehensive intake assessments, development of individualized care plans, proactive post-discharge interventions, and ongoing