Transitional Care RN - South Los Angeles

About my Place Health

my Place Health was founded in 2021 by mission-aligned healthcare leaders and organizations that are committed to drastically improving health outcomes, quality and experience for vulnerable older adults and frail seniors. We specialize in providing value-based, comprehensive care and coverage for older adults with significant needs so they can thrive in the homes they love and in the communities they cherish.

Our mission is simple: to enable older adults to live the independent lives they deserve. We pursue this mission through our my Place PACE (Program of All-Inclusive Care for the Elderly) model, which provides seamless primary care, integrated health plan coverage, personalized social engagement, and customized services delivered in the participant’s preferred place.

my Place Health is building a mission-driven team that shares our passion for redefining the way older adults experience care as they “age in place” in the community. This is a unique opportunity to take on one of our country’s most challenging healthcare problems and join a fast-growing, dynamic team as we prepare to scale our mission to serve more markets.

Are you a compassionate, mission-driven nursing professional who thrives in a collaborative environment? Do you seek a critical role in delivering high-quality, integrated care that empowers disabled older adults to live safely and independently?

As a Transitional Care RN at my Place Health, you will be at the heart of our commitment to providing seamless, patient-centered services across different sites of care. You’ll coordinate and manage healthcare transitions for our PACE participants, ensuring a smooth and safe journey between settings—including hospitals, skilled nursing facilities, clinic, home, and virtual care. Your expertise will proactively help to prevent complications, reduce avoidable readmissions, reduce emergency department visits, and improve health outcomes.

In this role, you will conduct comprehensive participant assessments, collaborate with the my Place interdisciplinary team, coordinate with planners and clinicians at partner facilities, educate families and caregivers, and advocate for participants’ needs every step of the way. If you're ready to make a lasting difference and help redefine the care experience for older adults, apply today and be part of a team that truly values your impact!

• Comprehensive Participant Assessment: Conduct thorough evaluations of participants during hospitalizations to identify risks for post-discharge complications and ensure a smooth transition.
• Inpatient Facility Coordination: 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.
• Care Transition 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 my Place interdisciplinary team.
• Utilization and Care Management: 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.
• Interdisciplinary Team
  
  Collaboration:
  
  Attend IDT meetings, hospital rounds, and SNF care conferences to align on participant discharge planning and ensure coordinated care.
• Discharge Coordination & Support: Arrange for appropriate post-discharge care, including medical equipment, medication delivery, and community support services, to prevent readmissions and align with participants’ care goals.
• Participant & Caregiver
  
  Education:
  
  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.
• Ongoing Follow-Up & Monitoring: Regularly check in with participants…