Transitional Care RN

Medix is looking to hire a Registered Nurse for a Full-time Transitional Care RN role with 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

For California Applicants:

We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO) , and the California Fair Chance Act (CFCA).

This position is subject to a background check based on its job duties, which may include patient care, working with vulnerable populations, access to financial and confidential information, driving, working with heavy machinery, or working in a warehouse or laboratory environment. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.