Upvote
Downvote
Transitions of Care RN
Share Job
- Suggest Revision
- Our seamless in-office and 24/7 virtual care services, on-site labs, and programs for preventive care, chronic care management, common illnesses and mental health concerns have been delighting people for the past fifteen years.
- The Transitions of Care RN will support the care of One Medical Senior Health patients discharged from ER visits/stays, acute, and post-acute stays, creating appropriate care plans, and working with internal and external care team members to coordinate care.
- Interact with internal and external care team members to provide complex coordination for patients needing short-term case management and safety interventions after discharge from acute care facilities, post-acute care facilities, or emergency departments.
- Serve as the primary liaison between partner providers and the patient’s primary care physician (PCP) team during time of transition, engaging in care planning, medication reconciliation, pre- and post-discharge planning, and facilitating safe handoffs of care.
- Address and resolve post-discharge barriers and potential readmission factors including home health, durable medical equipment, and social determinants of health.
Active Job
Updated 2 days agoSimilar Job
Relevance
Active