Registered Nurse, Care Transitions

About the role:

As the Registered Nurse, Care Transitions, you will be at the forefront of delivering seamless, high-impact care for patients with complex medical, behavioral health, and social needs. In this pivotal role, you will champion safe, coordinated transitions across care settings—helping patients stay healthy at home, reduce avoidable hospitalizations, and experience truly continuous, high-quality care.

You will serve as a vital connector between post-acute transitions and ongoing, integrated nursing support, ensuring patients feel supported, informed, and empowered every step of the way. This is an opportunity to make a tangible difference in patients’ lives while practicing at the top of your license.

You’ll join a collaborative, mission-driven multidisciplinary team that includes Physicians, Advanced Practice Clinicians, Health Advocates, Social Workers, Behavioral Health Clinicians, Psychiatrists, Pharmacists, and Patient Experience Navigators. Working closely with both local and centralized teams, you’ll deliver patient-centered care through a blend of virtual and telephonic services tailored to meet each patient’s unique needs.

As our innovative care model continues to grow and evolve, this role offers the opportunity to grow with it, helping shape the future of integrated, home-based care.

Responsibilities will include: 

Essential Functions 

• Provide post-discharge transitions of care support in order to reduce readmissions, rehospitalizations and ED revisits for patients recently discharged from emergency departments, hospitals, skilled nursing facilities, or behavioral health facilities. This includes: 
• Completing a RN visit and/or interaction within 7 days of discharge
• Performing clinical assessments, identifying red flags, and appropriately escalating to urgent care and/or supervising physicians when needed for patients at risk of decompensation and/or readmission
• Ensuring accurate medication reconciliation post-discharge, with appropriate medications in-hand and adherence to medication plan
• Scheduling and ensuring completion of a post-discharge visit with an AH provider within 7 days of discharge date for patients discharged from inpatient, observation, or SNF admissions
• Providing appropriate patient education, coaching and self-management support
• Identifying clinical, behavioral, and social barriers to recovery or stability and coordinate appropriate follow-up care and referrals
• Providing patient remote monitoring support when needed to ensure recovery and prevent decompensation
• Support proactive and longitudinal interactions for high-risk patients with frequent utilization to prevent avoidable inpatient and emergency department visits
• Conduct virtual (video, phone, text) nursing visits and interactions based on patient acuity, program needs, and care plans
• Collaborate closely with interdisciplinary care team members to ensure continuity of care aligned with patient goals and values
• Coordinate with external partners, including hospitals and community providers, to support safe discharge planning and reduce readmissions
• Maintain timely, accurate clinical documentation in the electronic medical record
• Utilize electronic data tools and dashboards to prioritize work, manage patient outreach, and monitor care outcomes
• Participate in triage and care transitions coverage as needed across markets, including holiday coverage per policy

Other Job Functions 

• Participate in quality improvement initiatives and provide feedback on workflows and program design
• Participate in team meetings, trainings, and occasional in-person team-building activities
• Performs other duties as assigned

What makes you a fit for the team:

• Deep commitment to caring for complex, historically underserved populations with compassion and dignity
• Comfort operating across care settings and adjusting between virtual, in-home, and transitional care workflows
• Strong clinical judgment and ability to work independently while remaining highly collaborative
• Passion for patient education, empowerment, and behavior change
• Excitement about contributing to an evolving, innovative, value-based care model
• Ability to adapt quickly, learn continuously, and contribute to team-based problem solving

Decision making authority: 

• Exercises moderate to high authority for standard decisions and limited to moderate authority for non-standard decisions that impact others.

Desired skills and experience: 

• Required
• Active Registered Nurse (RN) license in state of employment and willingness to obtain additional licensure as requested
• 2+ years of experience providing care to adult and/or geriatric patients with complex chronic medical conditions
• Demonstrated experience in transitions of care, including post-discharge follow-up, medication reconciliation, and care coordination
• Strong clinical assessment, critical thinking, and care coordination skills
• Experience delivering patient education and supporting chronic disease self-management
• Comfort working within interdisciplinary care teams, including clinical and non-clinical partners
• Proficiency with electronic medical records and technology-enabled care delivery 
• Strong skills in remote work, virtual communication, and prioritization to manage competing demands

• Preferred 
• Experience with virtual care, both telephonic and video
• Experience in home-based care, geriatrics, internal medicine, family medicine, palliative care, or value-based care organizations
• Experience caring for patients with serious mental illness and/or substance use disorders
• Experience in trauma-informed care
• Experience participating in quality improvement initiatives
• Multi-state RN licensure in at least one of the following states: MI, CO & MA (must be willing to obtain additional licenses - support and reimbursement provided)