Transition of Care RN

We value our employees! We offer long term employment opportunities with job stability, including supporting and encouraging career growth advancement.
We offer Health, Dental and Vision insurance, Paid Time Off, 9 Paid Holidays, 403(b) with Matching Retirement Plan, Life insurance (paid by the company) and a team spirit workplace culture! Candidates should be aware that Los Angeles Jewish Health (LAJH) currently maintains a policy requiring employees to be fully vaccinated.
New LAJH employees should be fully vaccinated (i.
e.
, two weeks after last dose) by their start date.
LAJH is an equal opportunity employer, and will provide reasonable accommodation to those unable to be vaccinated where it is not an undue hardship to the company to do so as provided under federal, state, and local law.
Under the supervision of the Case Management/Utilization Review supervisor, the Transition of Care RN is responsible for the development and implementation of Transition of care services for program participants.
Administrative Functions Using the nursing process provides semi-annual assessments and annual reassessments of assigned participants to evaluate Transition of care needs.
Records all assessments, reassessments and care in the electronic medical record.
Conducts reassessments to determine ongoing needs and develops and implements a therapeutic Plan of Care with recommendations at least quarterly and when a participant’s condition changes.
Presents and coordinates the Plan of Care with the Interdisciplinary Team.
Conducts home visits as needed to assess medical status and needs as recommended by the Interdisciplinary Care Team.
Coordinates and implements all transition of care services to include Nursing, Physical Therapy, Occupational Therapy, Speech Therapy and Home Care services to assure that quality services are provided to meet participants needs.
Completes and sends a level of care assessment tool (LOCAT) for all participants residing in contracted facilities.
Supervises home care for participants in board and care assisted living, residential care and other supportive housing arrangements according to BCSC standards.
Works with supportive housing staff to ensure effective communication and coordination of care.
Works closely with the Director of Quality and Compliance to oversee all activities related to quality assurance of Home Care and transition of care.
Works closely with the Center Manager and Director of Quality and Compliance to receive, document and resolve reports of participant rights violations, grievances, appeals and other issues related to service and quality of care.
Actively participates in Interdisciplinary Team meetings.
Education and Experience Degree and diplomas: Graduate of a school of professional nursing.
Certificates, Licenses: Licensed as RN through California Board of Registered Nursing.
Verification of completion of CPR (BLS) and first aid training.
TB screening and successful completion of a health examination by a health care provider is required for employment.
Must have a valid California driver’s license.
Experience: At least one year as an RN, preferably in home or community health care; at least one year working with the frail or elderly.
Skills/Aptitudes: Ability to provide home care for frail elderly.
Must be able to work effectively as part of an Interdisciplinary Team.
Specific Requirements Must be able to read, write, speak, and understand the English language.
Must possess the ability to make independent decisions when circumstances warrant such action.
Must possess the ability to deal tactfully with personnel, participants, visitors and the general public.
Must be knowledgeable of medical terminology, laws, and regulations as they pertain to long‑term care.
Must possess the ability to work harmoniously with other personnel.
Must possess the ability to minimize waste of supplies, misuse of equipment, etc.
Must be able to follow written and oral instructions.
Be knowledgeable in computers, data input and output.
Must be able to relate information concerning a participant’s condition