Transitional Care RN - 240555 New

Medix is looking to hire a Registered Nurse for a Full-time Transitional Care RN rolewith a growing organization in Los Angeles, providing personalized care and coverage to older adults.

Responsibilities:

• Conduct thorough evaluations of participants during hospitalizations to identify risks for post-discharge complications and ensure a smooth transition.
• Visit participants in hospitals or skilled nursing facilities (SNFs) as needed to assess their medical and functional status.
• Collaborate daily with providers and facility staff on treatment plans, care coordination, and discharge planning.
• Develop and implement individualized transition care plans, including medication management, follow-up appointments, and home care needs, in collaboration with participants, families, and the internal interdisciplinary team.
• Work closely with the Medical Director and interdisciplinary team (IDT) to determine hospital admissions, observation stays, and SNF placements.
• Attend IDT meetings, hospital rounds, and SNF care conferences.
• Arrange for appropriate post-discharge care, including medical equipment, medication delivery, and community support services.
• Educate participants and caregivers about medical conditions, treatment plans, medication adherence, and self-care strategies.
• Regularly check in with participants post-discharge via phone, telehealth, or home visits to assess progress, address concerns, and proactively intervene.
• Identify high-risk cases, anticipate potential challenges, and implement solutions to improve health outcomes and reduce hospital utilization.
• Maintain accurate and up-to-date records of participant assessments, care plans, interventions, and all communication with healthcare providers and team members.

Requirements / Experience:

• Active, unrestricted RN license in California.
• Minimum 3 years of experience caring for medically complex or older adult populations preferred. Experience with care coordination and managing multiple participant cases is a plus.
• Strong clinical acumen in geriatrics, cardiology, or other relevant specialties. Prior experience in wound care, IV therapy, phlebotomy, colostomy/ileostomy care is a plus.
• Familiarity with managed care, quality improvement, risk management, and interdisciplinary team collaboration.
• Bilingual in English and Spanish is preferred.
• Valid CA driver’s license

Schedule:

• Monday- Friday 8:00-5:00 pm
• 10-15% travel within the community to build and maintain relationships

Pay range:

$104,000-120,000/ annual salary (BOE)

Full benefits, including but not limited to Medical coverage, 401K, PTO, paid holidays, and more