Transitions Nurse – RN

The role

The Transitions Nurse works with Home Health clinical teams to identify patients with changing healthcare needs. They provide education, guidance, and coordination to ensure patients receive appropriate care levels, such as hospice or palliative care.

What you will do

• Work with Home Health clinicians to identify patients requiring different levels of care.
• Contact patients and families to provide education and coordinate resources.
• Assist patients and families in navigating transitions to hospice, palliative care, or placement.
• Maintain communication and follow-up with patients and families during transitions.
• Collaborate with Home Health nurses, therapists, and clinical leadership.
• Provide in-person informational sessions regarding hospice care and resources.
• Coordinate and facilitate transitions from Home Health to Hospice.
• Educate Home Health clinical teams on hospice appropriateness and indicators of decline.
• Provide hospice education and in-services to Home Health teams and community partners.
• Maintain accurate documentation of patient communication and transition status.

Required qualifications

• Current and unrestricted California Registered Nurse (RN) license.
• Minimum of 1 year of nursing experience.
• Knowledge of hospice, palliative care, and end-of-life care principles.
• Strong clinical judgment and ability to recognize changes in patient condition.
• Excellent communication and interpersonal skills.
• Strong organizational, follow-up, and care coordination skills.
• Ability to work independently while collaborating 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.

Nice to have

• Home Health, Hospice, palliative care, care transitions, or case management experience

Benefits

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

About the company

Health Link Home Health & Hospice is seeking an experienced Registered Nurse (RN) to join our growing Transitions Department.