Transitional Care Registered Nurse (RN)

Position Summary

The Transitional Care Registered Nurse (RN) is responsible for identifying high-risk patients at critical transition points, including emergency department visits and hospital discharges, and ensuring timely follow-up, care coordination, and engagement in ongoing care services.

This role serves as the primary driver of post-discharge care management and plays a critical role in reducing avoidable hospital utilization, improving patient outcomes, and supporting enrollment into existing Remote Patient Monitoring (RPM) services through partnerships such as Trilogy Health.

Required Qualifications:

• Current Registered Nurse (RN) license in the State of Texas
• Minimum of 2 - 3 years clinical experience (hospital or outpatient)
• Strong knowledge of care coordination and discharge processes

Preferred Qualifications:

Experience in:

• Case management or transitional care
• Chronic disease management
• Population health or quality programs
• Familiarity with EHR systems (e.g., CPSI/TruBridge)
• Experience with RPM or care management programs

Skills and Competencies (specific skills and competencies):

• Strong communication and patient engagement skills
• Ability to prioritize and manage high-risk patients
• Critical thinking and clinical assessment skills
• Ability to work independently and within a team-based model
• Organizational and documentation proficiency