Registered Nurse, Transition of Care

Registered Nurse, Transition of Care

Ensuring continuity of care when it matters most.

The Transition of Care RN plays a vital role in ensuring smooth, safe, and well-coordinated transitions for participants moving between care settings. Working under the QA/QI Manager and alongside the Interdisciplinary Team (IDT), this nurse serves as the primary liaison between the PACE program, community providers, facilities, participants, and families—ensuring continuity, communication, and high-quality care.

• Serve as the key point of contact between the PACE center, IDT, contracted facilities, home health agencies, participants, and caregivers

• Coordinate and monitor care during hospitalizations, skilled nursing stays, and dis

• Participate as an active member of the Interdisciplinary Team and contribute to individualized care plans

• Provide timely updates to the IDT on participant status, care changes, and provider orders

• Support safe discharge planning in collaboration with facilities, families, and community partners

• Conduct medication reconciliation between contracted providers and PACE primary care teams

• Complete accurate, timely documentation in the electronic medical record (EMR)

• Provide on-site visits as needed to support participant care and transitions

• Educate participants and caregivers on chronic conditions, care needs, and end-of-life considerations

• Maintain strong professional relationships with community partners and contracted providers

• Attend meetings, trainings, and committee work as assigned

• Follow all organizational policies, safety guidelines, and confidentiality standards

• Graduate of a board-approved nursing program

• Active Registered Nurse (RN) license in the state of Massachusetts

• Minimum of one year of RN experience working with frail or elderly populations in a community-based, long-term care, or similar setting

• Strong communication and relationship-building skills