As the Transition-of-Care / Telehealth Nurse, you will play a key role in ensuring continuity of care and safe transitions from hospital, skilled nursing, or other settings back to home or community for our participants. You will leverage telehealth tools, coordinate with the interdisciplinary team, monitor participants, identify and intervene on risk factors, and educate participants and caregivers. You’ll be the bridge between acute care settings and our PACE North home-based model, helping to reduce readmissions, enhance outcomes, and support participants’ goals of remaining safely in their homes.

Key Responsibilities

• 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; escalate to the appropriate provider when needed.
• Facilitate virtual or in-person check-ins within defined timeframes 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 interdisciplinary care team (nursing, social work, therapy, pharmacy, primary care) to ensure holistic care plan and participant goals are met.

 Schedule & Work Environment

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

Compensation & Benefits

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

Required:

• 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).

Preferred:

• 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.