myPlace Health · 5 hours ago
Transitional Care RN
East Compton, CA
Full-time
Hybrid
Mid Level
$50/hr - $60/hr
3+ years expmyPlace Health is dedicated to improving health outcomes for vulnerable older adults and frail seniors. As a Transitional Care RN, you will coordinate and manage healthcare transitions for participants, ensuring safe journeys between various care settings and preventing complications to improve health outcomes.
Elder CareHealth CareNon Profit
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 myPlace interdisciplinary team
Work closely with the Medical Director and interdisciplinary team (IDT) to determine hospital admissions, observation stays, and SNF placements, ensuring appropriate lengths of stay. Enter and manage authorizations to streamline claims processing
Attend IDT meetings, hospital rounds, and SNF care conferences to align on participant discharge planning and ensure coordinated care
Arrange for appropriate post-discharge care, including medical equipment, medication delivery, and community support services, to prevent readmissions and align with participants’ care goals
Educate participants and caregivers about medical conditions, treatment plans, medication adherence, and self-care strategies. Serve as the primary point of contact for guidance during the transition period
Regularly check in with participants post-discharge via phone, telehealth, or home visits to assess progress, address concerns, and proactively intervene to prevent complications or readmissions
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
Step in to support additional responsibilities as needed, ensuring our participants receive the highest quality care and our team thrives together
Qualification
Required
Active, unrestricted RN license in California
Minimum 3 years of experience caring for medically complex or older adult populations preferred
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
Experience with electronic health records (EHR) and healthcare technology platforms
Dedicated to improving healthcare outcomes for high-risk seniors and frail older adults
Ability to effectively engage with participants, families, and healthcare professionals both verbally and in writing
Proactively identifies challenges and implements effective solutions to support participant health and well-being
Thrives in fast-paced, dynamic environments and is comfortable working across multiple clinical settings
Skilled at understanding participant needs and addressing concerns with empathy and professionalism
Proof of current CPR/BLS certification or ability to obtain within 30 days of hire
Valid CA driver's license
Preferred
Alzheimer's Certification
Bilingual in English and Spanish
Benefits
401(k) plan with an employer match
Choose from six medical plans, with up to 80% of premiums covered for employees and 75% for dependents
Dental and vision insurance
FSA/HSA options
Short- and long-term disability
Basic life insurance
Additional benefits like accident, critical illness, and hospital indemnity coverage
20 days of PTO to start
12 paid holidays
2 floating holidays each year
Generous CME/CEU budget
Dedicated time off for learning
Paid parental leave
Child care stipend
Company
myPlace Health
myPlace Health delivers integrated medical and supportive care for seniors through the PACE model, helping them live independently.
51-200 employees
Funding
Current Stage
Growth StageTotal Funding
unknownKey Investors
SCAN Group
2025-05-20Acquired
2021-10-13Series Unknown
Leadership Team
R
Robbie Pottharst
Founder and CEO
Recent News
EIN Presswire
2025-08-06
Fierce Healthcare
2025-06-06
2025-06-04
Company data provided by crunchbase