Transitional Registered Nurse (PACE)

Job Description

myPlace 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, myPlace 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, myPlace 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 myPlace Health, work is more than a job. It’s a shared commitment to honoring what matters most. 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 myPlace 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 (Program of All-Inclusive Care for the Elderly) 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 myPlace interdisciplinary team, coordinate with planners and clinicians at our 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! 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 myPlace 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 myPlace'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 license. Alzheimer’s Certification: Preferred but not required. Tuberculosis Screening Policy To ensure the health and safety of our members, if you are selected for this position, your job offer with SCAN will be contingent on providing proof of Tuberculosis screening upon hire or providing proof of a negative screening within the last year. If you have a disability/medical reason or sincerely held religious belief that prevents you to provide information required in this policy, SCAN will initiate and engage in the interactive process to evaluate what, if any, reasonable accommodations may be available. What's in it for you? Base salary range: $44.42to $64.27 per year An annual employee bonus program Medical, Dental, Vision coverage Generous paid-time-off (PTO) 11 paid holidays per year, plus 1 additional floating holiday Excellent 401(k) Retirement Saving Plan with employer match. Robust employee recognition program Robust Wellness Program Tuition reimbursement #LI-KF1