Registered Nurse – Transitions of Care (Bilingual English/Spanish)

Built for the Nurse Who Is Building Something More This role was designed with a specific nurse in mind: someone who is clinically skilled, bilingual, deeply committed to patient care — and currently pursuing their Nurse Practitioner degree. If you are enrolled in an NP graduate program and struggling to find a position that respects your coursework, honors your clinical rotation commitments, and still pays a full-time income, this is that position. Our fully remote structure is not an afterthought. It is intentional. We built this role to give driven, career-advancing nurses the scheduling flexibility to attend virtual classes, complete coursework, and plan around clinical rotation requirements — while earning a meaningful salary and gaining population health experience that directly strengthens your NP foundation. This is a rare opportunity. We encourage you to apply.

About the Role

As a Registered Nurse in our Transitions of Care (TOC) program, you will serve as a key care coordinator for patients enrolled in our Accountable Care Organization (ACO). Your work will focus on the high-stakes period following hospital or skilled nursing facility (SNF) discharge — a time when patients are most vulnerable to readmission, medication errors, and gaps in follow-up care. You will serve as a trusted bridge between the patient and the care continuum: following up post-discharge, reconciling medications, connecting patients to resources, coordinating with physicians and specialists, and ensuring no patient falls through the cracks. You will conduct all patient interactions in both English and Spanish, meeting patients where they are and communicating with clarity, empathy, and cultural competence. This is mission-driven work. Every call you make, every appointment you confirm, and every care plan you coordinate contributes to better outcomes, lower readmissions, and a healthcare system that actually works for patients. Why This Role Stands Out For Nurses Currently in an NP Program, This Role Offers:

• A fully remote schedule with built-in flexibility to accommodate coursework and virtual classes
• Scheduling accommodations for clinical rotation requirements — discuss your needs during the interview process, and we will work with you
• Real-world experience in population health, chronic disease management, and care coordination — content that maps directly to your NP clinical and didactic training
• Continuing education support and tuition assistance to help you cross the finish line
• A full-time W2 income so you can focus on your degree without financial compromise

Key Responsibilities

• Conduct post-discharge outreach calls (phone and telehealth) to patients within 48–72 hours of hospital or SNF discharge
• Perform medication reconciliation and provide education on medication adherence and safety
• Assess patients for social determinants of health (SDOH) and connect them to appropriate community resources
• Schedule and confirm follow-up appointments with primary care providers and specialists
• Document all patient interactions thoroughly and accurately in the EHR (Epic preferred)
• Collaborate with the interdisciplinary care team on complex and high-risk cases
• Identify and escalate high-risk patients for more intensive care management interventions
• Conduct patient education in both English and Spanish, adjusting communication to match each patient's health literacy level
• Support organizational quality metrics and contribute to HEDIS/CMS quality measure reporting

Required Qualifications

• Active, unencumbered Registered Nurse (RN) license in a Nurse Licensure Compact (NLC) state
• Bilingual fluency in English and Spanish required
• Minimum 2 years of clinical nursing experience, preferably in med/surg, primary care, case management, or home health
• Strong working knowledge of care transitions, chronic disease management, and population health principles
• Proficiency with EHR/EMR systems (Epic experience preferred)
• Reliable high-speed internet and a dedicated, private home workspace
• Strong interpersonal and communication skills with the ability to build meaningful rapport with patients over the phone and via telehealth

Ideal Candidate: Currently enrolled in an accredited Nurse Practitioner (NP) graduate program. Candidates in an NP program are strongly preferred and will be prioritized. This role was built with your schedule and career trajectory in mind.

Preferred Qualifications

• Experience working in an ACO, Patient-Centered Medical Home (PCMH), or value-based care environment
• Familiarity with Medicare and/or Medicaid populations
• Experience with HEDIS measures or CMS quality improvement programs
• Certification in Case Management (CCM) or Ambulatory Care Nursing (RN-BC)

Who We Are We are an Accountable Care Organization committed to transforming how care is delivered to complex, high-need patient populations. Our model is built on coordination, prevention, and relationship — not volume. We believe that when nurses are supported, patients thrive. We invest in the people on our care teams because we know they are the reason our model works. If you are a bilingual RN who wants to grow clinically, advance professionally, and make a measurable difference in the lives of patients — we want to hear from you. Apply tot his job Apply To this Job