Transitional Care Navigator

01 Salinas Valley Health Medical Center; Salinas (CA); On-site; USD 91,000 - 125,000; Full time

Job summary

Salinas Valley Health in Salinas, CA is seeking a Transitional Care Coordinator to ensure smooth hospital-to-home transitions and reduce readmissions by coordinating post-discharge plans across care settings. The role interfaces with patients, families, and care teams to optimize outcomes.

Requires an Associate Degree in Nursing, CA RN license, and 3 years of nursing experience; bilingual in Spanish is required, BSN preferred. Day shift, 1.0 FTE, 40 hours.

Qualifications

• Associate Degree in nursing is required; BSN preferred.
• Current California RN license required; BLS/Healthcare Provider status required.
• Three years of nursing experience; bilingual in Spanish required; knowledge of post-acute care coordination and case management.

Responsibilities

• Meet eligible patients before discharge and assess barriers to outpatient care.
• Coordinate with Transitional Care leadership and social work to address barriers.
• Call patients within 24-48 hours after discharge to reinforce discharge plan.
• Follow up with Virtual Home Program patients as required, with frequent contact.
• Educate patients and families for at least 30 days post-discharge.
• Intervene to reduce avoidable ER visits and hospital admissions.
• Provide disease- and medication-related education as needed.
• Monitor vital signs and reinforce education on schedules and equipment use.
• Document all interactions and care plans in the EMR.
• Facilitate follow-up appointments with PCP and specialists.
• Collaborate with program leadership to address identified barriers.

Skills

Bilingual in Spanish

Education

Associate Degree in nursing

BSN preferred

Tools

EMR

Job description

Salinas Valley Health in Salinas, CA is seeking a Transitional Care Coordinator to ensure smooth hospital-to-home transitions and reduce readmissions by coordinating post-discharge plans across care settings. The role interfaces with patients, families, and care teams to optimize outcomes.

Requires an Associate Degree in Nursing, CA RN license, and 3 years of nursing experience; bilingual in Spanish is required, BSN preferred. Day shift, 1.0 FTE, 40 hours.