RN Telehealth and Care Transition

RN Telehealth and Care Transition

Join PACE North as an RN Telehealth and Care Transition nurse, playing a key role in ensuring continuity of care and safe transitions from hospital, skilled nursing, or other settings back to home or community for participants.

• Conduct telehealth assessments (video/phone) of participants post-discharge or during transitions of care.
• Review discharge summaries, medication reconciliations, and care plans to identify gaps or risks.
• Coordinate with hospital/rehab staff, home health agencies, case managers, pharmacy, primary care and our PACE interdisciplinary team (IDT) to develop and execute a safe transition plan.
• Educate participants and caregivers on post-discharge care, self-management, medications, red-flags, follow-up appointments, telehealth access, and home safety.
• Monitor participants remotely (via telehealth or monitoring tools) for changes in condition, adherence, symptoms, or early warning signs; elevate to appropriate provider when needed.
• Facilitate virtual or in-person check‑ins within defined time frames post‑discharge (e.g., within 24‑48 hours).
• Maintain accurate and timely documentation in the electronic health record (EHR) of telehealth encounters, transition plans, follow‑ups, and communications.
• Participate in the on‑call/after‑hours telehealth rotation as required.
• Provide input into quality improvement initiatives related to transitions of care/readmissions, telehealth effectiveness, and remote monitoring outcomes.
• Collaborate with the interdisciplinary care team (nursing, social work, therapy, pharmacy, primary care) to ensure holistic care plan and participant goals are met.

• Primary schedule:
  Monday‑Friday, daytime hours. This is an on‑site role.
• On‑call/telehealth rotation evenings or weekends may be required as part of the transition team.

• Competitive salary (based on experience and qualifications).
• Generous PTO and paid holidays from day one.
• Comprehensive benefits including health, dental, vision, life insurance, short‑/long‑term disability.
• 401(k) with match.
• Professional development opportunities.
• Supportive team culture and mission‑driven work.

• Current, valid Registered Nurse (RN) license in Michigan.
• Minimum of 2 years nursing experience; experience with care transitions, home care, geriatrics, or telehealth preferred.
• Strong critical thinking skills; ability to manage ambiguity and changing priorities.
• Excellent communication skills (verbal, written); ability to interface with diverse participants, caregivers, providers, and care team.
• Comfortable with technology (telehealth platforms, EHR, remote monitoring tools).
• Valid driver’s license and reliable transportation for occasional home/field visits.

• Bachelor of Science in Nursing (BSN).
• Experience with the PACE model or working with older adult/frail populations.
• Experience with hospital discharge planning or readmissions prevention programs.
• Familiarity with CMS rules/regulations as they pertain to PACE programs.