The Transitions Nurse works closely with our Home Health clinical teams to identify patients whose healthcare needs are changing and help ensure they receive the appropriate level of care, services, and support. This may include hospice, palliative care, additional caregiving support, higher levels of care, placement, or other community resources based on the patient’s individual needs.

The Transitions Nurse serves as a consistent resource for patients and families throughout these changes, providing education, guidance, coordination, and follow-up to help ensure patients receive the right care at the right time.

A key component of the role includes identifying patients who may be appropriate for hospice, providing hospice education and informational visits, and facilitating timely transitions when hospice becomes the appropriate level of care.

JOB REQUIRES ON-SITE AND FIELD-BASED WORK

Key Responsibilities

• Work closely with Home Health clinicians to identify patients whose healthcare needs are changing and may require additional services or a different level of care.
• Proactively contact patients and families to understand changing needs, provide education, discuss available options, and coordinate appropriate resources and services.
• Assist patients and families in navigating transitions to hospice, palliative care, additional caregiving support, higher levels of care, placement, or other appropriate community resources.
• Maintain ongoing communication and follow-up with patients and families throughout the transition process to help ensure their needs are addressed.
• Collaborate with Home Health nurses, therapists, and clinical leadership to identify patients who may be appropriate for hospice and ensure timely follow-up.
• Provide in-person informational sessions to patients, families, and caregivers regarding hospice care, services, benefits, and available resources.
• Coordinate and facilitate seamless transitions from Home Health to Hospice when appropriate.
• Educate Home Health clinical teams on hospice appropriateness, indicators of decline, changing patient needs, and when additional services or a different level of care should be considered.
• Provide hospice education and in-services to Home Health teams and community healthcare partners.
• Collaborate with physicians, nurses, therapists, social workers, Hospice staff, and other healthcare professionals to support appropriate and timely transitions.
• Serve as a consistent point of contact for patients and families throughout changes in their healthcare needs.
• Maintain accurate and timely documentation of patient and family communication, follow-up activities, resources provided, and transition status.

Qualifications

• Current and unrestricted California Registered Nurse (RN) license.
• Minimum of 1 year of nursing experience, with Home Health, Hospice, palliative care, care transitions, or case management experience preferred.
• Knowledge of hospice, palliative care, and end-of-life care principles.
• Strong clinical judgment and ability to recognize changes in patient condition and care needs.
• Excellent communication and interpersonal skills, including the ability to have sensitive conversations with patients and families.
• Strong organizational, follow-up, and care coordination skills.
• Ability to work independently while collaborating effectively with multidisciplinary teams.
• Comfortable providing education and presentations to clinical teams and community partners.
• Valid driver’s license and reliable transportation for patient and community visits.

Pay Range

RN: $55–$65/hour

Benefits

• Health, Dental, and Vision Insurance
• 401(k) with matching
• Life Insurance
• Paid Time Off (PTO)
• Flexible Schedule
• Flexible Spending Account (FSA)