Transitional Care RN

Job Summary And Responsibilities As our Transitional Care Nurse (TCN), you will serve as a pivotal leader in the Nebraska Rural Health Transformation Program (RHTP), a specialized, grant-funded initiative dedicated to advancing healthcare delivery in rural communities. You will spearhead our Remote Patient Monitoring (RPM) program, collaborating with clinical vendors to deploy innovative medical technology and provide essential physician oversight for clinical escalation. By streamlining care coordination and strengthening chronic disease management, you will play a critical role in reducing avoidable emergency department visits and readmissions for patients managing conditions like diabetes, COPD, and cardiovascular disease. Every day you will manage the operational and administrative lifecycle of this grant-funded program, utilizing Epic analytics and predictive metrics to identify high-risk patients. Your daily workflow includes reviewing discharge orders, leading clinical huddles, and facilitating seamless transitions through patient consent, device provisioning, and comprehensive education. You will act as the primary point of contact for patients and interdisciplinary healthcare teams, ensuring that every transition plan is meticulously documented in the electronic medical record and tailored to the patient’s specific home health needs. To be successful in this role, you will possess sharp clinical judgment and the ability to bridge the gap between hospital-based care and long-term outpatient recovery. You will demonstrate proficiency in EPIC documentation and have the interpersonal skills necessary to build rapport with patients during bedside consultations. We are looking for a proactive, organized nursing professional who thrives in a collaborative environment—partnering with Case Management, nursing staff, and physicians to drive the goals of the RHTP grant and provide the education necessary to ensure long-term health success for our rural patient population. Required Job Requirements 1-3 years Clinical RN in an acute care setting., upon hire and Registered Nurse: NE, upon hire and Basic Life Support - CPR, upon hire Preferred Bachelors Of Science Nursing or a Related Field, upon hire Where You'll Work CHI Health St. Francis was established in Grand Island, Neb. in 1887. Today, our hospital is a regional referral center, with more than 100 physicians and more than 1,100 team members working together to build a healthier community. Our goal is to provide patients with high-quality medical care close to home, where they can be supported by their family, friends, and community. Pay Range $32.70 - $48.65 /hour