RN Transitional Care - FT Days (8am-4:30pm)
Company: Martin Luther King, Jr. Community Hospital
Location: Huntington Park
Posted on: January 8, 2026
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Job Description:
If you are interested, please apply and send your resume to
yadeleon@mlkch.org. POSITION SUMMARY The Transitional Care nurse
(TCN) will ensure the coordination and continuity of healthcare as
patients transition between different locations or levels of care.
The TCN will assist with complex patients, focus on high hospital
utilizers, chronically ill and educate patients and family
caregivers to determine the root cause to poor health outcomes that
may lead to readmission to the hospital. The TCN will work with the
Manager of Case Management, Care Managers and hospitalists to
determine a safe discharge plan and ensure patient's continuity of
care upon discharge. ESSENTIAL DUTIES AND RESPONSIBILITIES
Responsible for post discharge contact on a case-by-case concern
with Medicare, other payers, and other identified complex patients,
observation and inpatient, to determine that a safe discharge plan
has been fully implemented. Works with the Manager of Post-Acute
Services Care Networks, Care Management Manager, Social Work and
other members of the CM team to identify patients requiring follow
up assessments and identification of criteria for patients
requiring follow up phone calls or other contact. Assess identified
cases and utilize the information and available benefits/resources
to assist the patient, family/caregiver and provider. Document all
activities specific to interventions for patients contacted in the
electronic medical record. Coordinates services in an effort to
provide integrated health services for each patient and provide
benefit and health information to each patient so they are able to
make informed health decisions. Assesses patient needs and make
referral to any needed follow up services such as but not limited
to MLKCH PDC, community resources, primary care provider, disease
management, or other services. Promote the mission and core values
of MLKCH. Document each call with all pertinent information along
with interventions performed in a call log. Acts as a consultant
for the Transitional Care Navigator Lead or other members of the CM
team. Participates in performance improvement projects, initiatives
and performs data collection for measurement of projects as
assigned. Works closely with Post-Acute Services to ensure that
patients in settings other than home are appropriately placed post
recuperative. Has authority to add or extend services as needed to
prevent readmission to MLKCH. May participate in interdisciplinary
discharge planning teams to ensure smooth transition from inpatient
to outpatient services. Meets regularly with CM Leadership &
Post-Acute Network Manager to identify opportunities or trends to
improve patient care. Acts as CM with any recently acquired
insurance; communicates and educates patient and family as needed
in obtaining assistance from PCP or PDC. Must utilize Translator
assistance devices as needed to improve communications with
patients and families. Work with management to identify and vet
potential post-acute service providers, as well as complete site
visits to skilled nursing facilities with management to ensure MLK
funded patients are receiving all necessary post-acute services.
Perform other duties as assigned. POSITION REQUIREMENTS A.
Education BSN required. CCM or ACM certification within 2 years of
hire. B. Qualifications/Experience Three (3) years of experience in
Care Management either acute care or telephonic Care
Management/Disease Management. Current California Nursing license.
Current Basic Life Support (BLS) for Health Care Providers from the
American Heart Association. Valid unrestricted CA Driver's License
and valid proof of vehicle insurance. Prior case management
experience in an acute care setting, medical office or health
advice RN preferred. Bi-lingual Spanish preferred. C. Special
Skills/Knowledge Proficient to expert computer skills utilizing
Microsoft Office especially Word and Excel Must be customer service
driven and be resourceful while utilizing high level of critical
thinking skills. A team player that can follow a system and
protocol to achieve a common goal Highly organized and well
developed oral and written communication, problem-solving, and
decision-making skills. LI-YD1 MLKCH Video
Keywords: Martin Luther King, Jr. Community Hospital, Huntington Park , RN Transitional Care - FT Days (8am-4:30pm), Healthcare , Huntington Park, California
