Transitional Registered Nurse

my Place Health is built around a simple but powerful belief: older adults deserve the support they need to live safely, independently, and with dignity in their own communities. As a PACE (Program of All Inclusive Care for the Elderly) organization backed by SCAN Group, my Place Health brings together customized medical care, social activities, and daily support for participants and their families – all under one roof.

Our centers are more than healthcare facilities. They are vibrant community hubs where participants are known by name, valued, and supported as whole people. Behind that experience is a dedicated, interdisciplinary team working together to coordinate care, remove barriers, and improve quality of life for some of the most medically and socially complex populations.

For employees, my Place Health offers the opportunity to do deeply meaningful work in a highly collaborative setting. Team members are encouraged to contribute innovative ideas, and grow alongside a mission that prioritizes compassion, respect, and impact. The result is a culture where people feel connected—to their colleagues, their participants, and the communities they serve.

At my Place Health, work is more than a job. It’s a shared commitment to honoring what matters most.

RESPONSIBILITIES:

Comprehensive Participant Assessment:
Conduct thorough evaluations of participants during hospitalizations to identify risks for post-discharge complications and support a smooth transition.

Inpatient Facility Coordination:
Visit participants in hospitals or skilled nursing facilities (SNFs) as needed to assess medical and functional status and collaborate 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 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 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:
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.

Complex Case Management:
Identify high-risk cases, anticipate challenges, and implement solutions to improve health outcomes and reduce hospital utilization.

Effective Communication & Documentation:
Maintain accurate and up-to-date records of participant assessments, care plans, interventions, and communication with healthcare providers and team members; embrace flexibility and teamwork to support additional responsibilities as needed.

We seek Rebels who are curious about AI and its power to transform how we operate and serve our members.

Actively support the achievement of my Place's Vision and Goals.

Other duties as assigned.

QUALIFICATIONS &

EXPERIENCE:

Experience

Required:

Registered Nurse (RN) License:
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.

CPR/BLS Certification:
Proof of current certification or ability to obtain within 30 days of hire.

Valid CA driver’s…