About the role
Accompany Health is hiring a Registered Nurse for care transitions to support patients with complex medical, behavioral, and social needs after they leave the hospital, ER, or a facility. You'll work virtually and by phone to cut readmissions through medication reconciliation, education, and follow-up care. The role is remote across the US, and your RN license must be valid in your state of employment.
Responsibilities
- Complete an RN visit or interaction within 7 days of a patient's discharge from an ED, hospital, skilled nursing, or behavioral health facility
- Assess patients clinically, spot red flags, and escalate to urgent care or supervising physicians when needed
- Reconcile medications after discharge and confirm patients have what they need and are taking it as planned
- Schedule and confirm a post-discharge visit with an Accompany Health provider within 7 days
- Teach and coach patients on self-management of chronic conditions
- Find clinical, behavioral, and social barriers to recovery and coordinate referrals and follow-up
- Provide remote monitoring support and ongoing outreach to high-risk patients who use care frequently
- Coordinate with hospitals and community providers, and document in the EMR
Requirements
- Active RN license in your state of employment, and willingness to obtain additional licenses on request
- 2+ years caring for adult or geriatric patients with complex chronic conditions
- Demonstrated experience with transitions of care, including post-discharge follow-up and medication reconciliation
- Strong clinical assessment, critical thinking, and care coordination skills
- Comfort with electronic medical records and virtual communication
- Preferred: telephonic and video care experience; home-based, geriatric, palliative, or value-based care background
- Preferred: multistate RN licensure in MI, CO, or MA (support and reimbursement for additional licenses provided)
What we offer
- Support and reimbursement for additional state licenses
- Virtual and telephonic care model with an interdisciplinary team
- Possible bonus, equity, and benefits depending on the role
- Opportunity to help shape a growing integrated care model