Transitional Care - RN

Luminis Health, Inc.; Lanham (MD); On-site; USD 100,404,000 - 150,577,000; Full time

Benefits offered by this job

Medical, Dental, Vision Insurance

Retirement Plan with employer match

Paid Time Off

Tuition Assistance

Employee Referral Bonus

Paid Holidays, Disability, and Life/AD

Wellness Programs

Employee Assistance Programs

Job summary

Luminis Health is seeking a Transitional Care-RN to design and implement care transition processes for vulnerable patients across inpatient and outpatient settings. You will collaborate with care coordinators, clinicians, and community partners to ensure coordinated and effective transitions.

The role emphasizes patient-centered navigation, protocol design, and program development to improve health outcomes for individuals and populations.

Qualifications

• Bachelor of Science in Nursing preferred.
• Three years of nursing experience in general medicine, inpatient and outpatient settings.
• Current Maryland Board of Nursing license.
• CPR through the American Heart Association (BLS for Healthcare Providers).

Responsibilities

• Collaborate with care teams to build a network of resources for targeted patients.
• Design protocols guiding navigation of patients across care settings.
• Coordinate treatment plans and progress reports with clinicians.
• Assess needs of inpatients and families and coordinate with care teams.
• Serve as a clinical resource for nurse navigators and the Care Management Team.
• Contribute to annual goals and objectives for the Care Transitions Program.
• Identify educational needs and improve educational materials.
• Build relationships to improve health outcomes for individuals and populations.
• Support professional growth and program development.

Skills

Nursing

Care coordination

Education

Bachelor of Science in Nursing

Job description

Title

Transitional Care-RN

Job Code

001600

FLSA Status

Non - xempt

Position Objective

To design, implement, and foster care transition processes for our most vulnerable patients to maintain and enhance their health status and independence. This employee will be a specialist in navigating at-risk pediatric and adult patients across care settings. The employee will work with inpatient and outpatient clinical resources, community-based organizations, and families to build supportive networks to maintain or improve health status of individuals and populations. The position demands creativity, energy, and commitment to build a program for targeted patients.

Essential Job Duties

• Collaborates with care coordinators, inpatient and outpatient clinicians, the emergency department, patients, families, nursing facilities, pharmacy, home health agencies, hospice, community organizations, etc., to form lasting relationships that support a network of resources for targeted patients.
• Participates in the design of protocols that guide the navigation of targeted patients across all care settings.
• Coordinates the treatment plan and progress reports with clinicians to ensure engagement and success.
• Directly assess the needs of targeted inpatients and their families, and work with care coordination team members to meet those needs.
• Serves as a clinical resource for nurse navigators and Care Management Team.
• Participates in the preparation/achievement of annual goals and objectives for the Care Transitions Program.
• Identifies educational needs of patients and families and evaluate and improve educational media and content.
• Build supportive relationships and networks to maintain or improve health status of individuals and populations.
• Promotes own professional growth and development and applies to improve overall program success.

Educational/Experience Requirements

Bachelor of Science in Nursing, preferred.

Required Minimum Experience

Three years of nursing experience in general medicine, ideally including inpatient and outpatient settings.

Required License/Certifications

• Current Maryland Board of Nursing license.
• CPR through the American Heart Association (BLS for Healthcare Providers level).

Working Conditions, Equipment, Physical Demands

There is a reasonable expectation that employees in this position will be exposed to blood-borne pathogens.

The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.

Pay Range

$35.04—$52.55 USD

Luminis Health Benefits Overview

• Medical, Dental, and Vision Insurance
• Retirement Plan (with employer match for employees who work more than 1000 hours in a calendar year)
• Paid Time Off
• Tuition Assistance Benefits
• Employee Referral Bonus Program
• Paid Holidays, Disability, and Life/AD&D for full-time employees
• Wellness Programs
• Employee Assistance Programs and more
• Benefit offerings based on employment status