What are the responsibilities and job description for the Transitional Care RN position at myPlace Health?
About MyPlace Health
myPlace Health was founded in 2021 by mission-aligned healthcare leaders and organizations that are committed to drastically improving health outcomes, quality and experience for vulnerable older adults and frail seniors. We specialize in providing value-based, comprehensive care and coverage for older adults with significant needs so they can thrive in the homes they love and in the communities they cherish.
Our mission is simple: to enable older adults to live the independent lives they deserve. We pursue this mission through our myPlace PACE (Program of All-Inclusive Care for the Elderly) model, which provides seamless primary care, integrated health plan coverage, personalized social engagement, and customized services delivered in the participant’s preferred place.
myPlace Health is building a mission-driven team that shares our passion for redefining the way older adults experience care as they “age in place” in the community. This is a unique opportunity to take on one of our country’s most challenging healthcare problems and join a fast-growing, dynamic team as we prepare to scale our mission to serve more markets.
About This Role
Are you a compassionate, mission-driven nursing professional who thrives in a collaborative environment? Do you seek a critical role in delivering high-quality, integrated care that empowers disabled older adults to live safely and independently?
As a Transitional Care RN at myPlace Health, you will be at the heart of our commitment to providing seamless, patient-centered services across different sites of care. You’ll coordinate and manage healthcare transitions for our PACE (Program of All-Inclusive Care for the Elderly) participants, ensuring a smooth and safe journey between settings—including hospitals, skilled nursing facilities, clinic, home, and virtual care. Your expertise will proactively help to prevent complications, reduce avoidable readmissions, reduce emergency department visits, and improve health outcomes.
In this role, you will conduct comprehensive participant assessments, collaborate with the myPlace interdisciplinary team, coordinate with planners and clinicians at our partner facilities, educate families and caregivers, and advocate for participants’ needs every step of the way. If you're ready to make a lasting difference and help redefine the care experience for older adults, apply today and be part of a team that truly values your impact!
What Does Success Look Like As Our Transitional Care Rn?
As a Transitional Care RN, you’ll be the reassuring voice and skilled guide patients and families rely on during some of the most important moments of their lives.
If you’re someone who thrives on building trust, loves empowering patients to feel confident and cared for, and wants to leave a meaningful mark on every life you touch — we can’t wait to meet you.
Join us in creating smoother transitions, brighter outcomes, and a truly compassionate care experience. Apply today and let’s make an impact together!
Your Application
Please submit your resume/CV.
Our Commitment to Diversity, Equity and Inclusion
At myPlace Health, we value the diversity of our team members, and we are committed to building a culture of inclusion and belonging. We pride ourselves to be an equal opportunity employer. People seeking employment at myPlace Health are considered without regard to race, color, religion, sex, gender, gender identity, gender expression, sexual orientation, marital or veteran status, age, national origin, ancestry, citizenship, physical or mental disability, medical condition, genetic information or characteristics (or those of a family member), pregnancy or other status protected by applicable law.
COVID-19 Vaccination Policy
At myPlace Health, we provide safe and high-quality care to our participants. To achieve this, we have a policy that strongly recommends Covid-19 vaccination to keep both our team members and participants safe. Medical and religious exemptions can be granted based upon review of proper documentation. We adhere to all federal, state, and local regulations by obtaining necessary proof of vaccination prior to employment.
Beware of Scams and Fraud
Please beware of scams that solicit interviews or promote jobs for opportunities that are not listed on our website or are not directly related to a job you applied for yourself. Please be advised that myPlace Health will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission by selecting the ‘Rip-offs and Imposter Scams’ option: https://reportfraud.ftc.gov/#/
We may use artificial intelligence (AI) tools to support parts of the hiring process, such as reviewing applications, analyzing resumes, or assessing responses. These tools assist our recruitment team but do not replace human judgment. Final hiring decisions are ultimately made by humans. If you would like more information about how your data is processed, please contact us.
What’s In It for You?
At myPlace Health, we believe that when we take exceptional care of our people, they can take exceptional care of our participants. That’s why we’ve built a comprehensive, people-first rewards package designed to support your well-being—professionally, financially, and personally.
Here’s a snapshot of what you can look forward to:
Competitive Pay & Total Rewards
We offer a strong base salary along with a total rewards package that reflects your experience, education, certifications, and the location of your role. For onsite roles, we adjust pay based on local markets; remote roles are aligned to national pay benchmarks.
Performance-Based Incentives
Our industry-leading incentive plan recognizes your contributions and rewards success based on the performance of both your team and the organization.
Ongoing Growth & Feedback
You’ll receive two performance reviews per year (when applicable), giving you the chance to grow, reflect, and celebrate your achievements.
Plan for Your Future
Take advantage of our 401(k) plan with an employer match—because your future matters.
Health Coverage that Fits Your Life
Choose from six medical plans, with up to 80% of premiums covered for employees and 75% for dependents.
More Than Just Medical
We’ve got you covered with dental and vision insurance, FSA/HSA options, short- and long-term disability, basic life insurance, and additional benefits like accident, critical illness, and hospital indemnity coverage.
Generous Time Off
Recharge with 20 days of PTO to start, 12 paid holidays, and 2 floating holidays each year.
Support for Your Learning
We prioritize your professional development with a generous CME/CEU budget, dedicated time off for learning, and ongoing growth opportunities.
Family Comes First
Our family-friendly culture includes paid parental leave and a child care stipend to help support you at home.
myPlace Health was founded in 2021 by mission-aligned healthcare leaders and organizations that are committed to drastically improving health outcomes, quality and experience for vulnerable older adults and frail seniors. We specialize in providing value-based, comprehensive care and coverage for older adults with significant needs so they can thrive in the homes they love and in the communities they cherish.
Our mission is simple: to enable older adults to live the independent lives they deserve. We pursue this mission through our myPlace PACE (Program of All-Inclusive Care for the Elderly) model, which provides seamless primary care, integrated health plan coverage, personalized social engagement, and customized services delivered in the participant’s preferred place.
myPlace Health is building a mission-driven team that shares our passion for redefining the way older adults experience care as they “age in place” in the community. This is a unique opportunity to take on one of our country’s most challenging healthcare problems and join a fast-growing, dynamic team as we prepare to scale our mission to serve more markets.
About This Role
Are you a compassionate, mission-driven nursing professional who thrives in a collaborative environment? Do you seek a critical role in delivering high-quality, integrated care that empowers disabled older adults to live safely and independently?
As a Transitional Care RN at myPlace Health, you will be at the heart of our commitment to providing seamless, patient-centered services across different sites of care. You’ll coordinate and manage healthcare transitions for our PACE (Program of All-Inclusive Care for the Elderly) participants, ensuring a smooth and safe journey between settings—including hospitals, skilled nursing facilities, clinic, home, and virtual care. Your expertise will proactively help to prevent complications, reduce avoidable readmissions, reduce emergency department visits, and improve health outcomes.
In this role, you will conduct comprehensive participant assessments, collaborate with the myPlace interdisciplinary team, coordinate with planners and clinicians at our partner facilities, educate families and caregivers, and advocate for participants’ needs every step of the way. If you're ready to make a lasting difference and help redefine the care experience for older adults, apply today and be part of a team that truly values your impact!
What Does Success Look Like As Our Transitional Care Rn?
- Comprehensive Participant Assessment: Conduct thorough evaluations of participants during hospitalizations to identify risks for post-discharge complications and ensure a smooth transition.
- Inpatient Facility Coordination: Visit participants in hospitals or skilled nursing facilities (SNFs) as needed to assess their medical and functional status. Collaborate daily with providers and facility staff on treatment plans, care coordination, and discharge planning.
- Care Transition Planning: Develop and implement individualized transition care plans, including medication management, follow-up appointments, and home care needs, in collaboration with participants, families, and the myPlace interdisciplinary team.
- Utilization and Care Management: Work closely with the Medical Director and interdisciplinary team (IDT) to determine hospital admissions, observation stays, and SNF placements, ensuring appropriate lengths of stay. Enter and manage authorizations to streamline claims processing.
- Interdisciplinary Team Collaboration: Attend IDT meetings, hospital rounds, and SNF care conferences to align on participant discharge planning and ensure coordinated care.
- Discharge Coordination & Support: Arrange for appropriate post-discharge care, including medical equipment, medication delivery, and community support services, to prevent readmissions and align with participants’ care goals.
- Participant & Caregiver Education: Educate participants and caregivers about medical conditions, treatment plans, medication adherence, and self-care strategies. Serve as the primary point of contact for guidance during the transition period.
- Ongoing Follow-Up & Monitoring: Regularly check in with participants post-discharge via phone, telehealth, or home visits to assess progress, address concerns, and proactively intervene to prevent complications or readmissions.
- Complex Case Management: Identify high-risk cases, anticipate potential challenges, and implement solutions to improve health outcomes and reduce hospital utilization.
- Effective Communication & Documentation: Maintain accurate and up-to-date records of participant assessments, care plans, interventions, and all communication with healthcare providers and team members.
- Embrace flexibility and teamwork: Step in to support additional responsibilities as needed, ensuring our participants receive the highest quality care and our team thrives together.
- Registered Nurse (RN) License: Active, unrestricted RN license in California.
- Clinical Experience: Minimum 3 years of experience caring for medically complex or older adult populations preferred. Experience with care coordination and managing multiple participant cases is a plus.
- Specialized Skills: Strong clinical acumen in geriatrics, cardiology, or other relevant specialties. Prior experience in wound care, IV therapy, phlebotomy, colostomy/ileostomy care is a plus.
- Care Coordination Expertise: Familiarity with managed care, quality improvement, risk management, and interdisciplinary team collaboration.
- Technology Proficiency: Experience with electronic health records (EHR) and healthcare technology platforms.
- Passion for Mission-Driven Work: Dedicated to improving healthcare outcomes for high-risk seniors and frail older adults.
- Excellent Communication Skills: Ability to effectively engage with participants, families, and healthcare professionals both verbally and in writing.
- Strong Problem-Solving Abilities: Proactively identifies challenges and implements effective solutions to support participant health and well-being.
- Adaptability & Teamwork: Thrives in fast-paced, dynamic environments and is comfortable working across multiple clinical settings.
- Active Listening & Conflict Resolution: Skilled at understanding participant needs and addressing concerns with empathy and professionalism.
- CPR/BLS Certification: Proof of current certification or ability to obtain within 30 days of hire.
- Alzheimer’s Certification: Preferred but not required.
- Language Skills: Bilingual in English and Spanish is preferred.
- Transportation & Compliance: Valid CA driver’s license
- Move freely and safely throughout a variety of care environments, including participant homes, clinics, and skilled nursing facilities.
- Stand, walk, bend, squat, and reach for extended periods during participant assessments, medication administration, and care coordination tasks.
- Lift, transfer, and assist participants as needed—up to 50 pounds—with the use of appropriate body mechanics or mobility equipment.
- Perform fine motor tasks, including taking vital signs, administering medications, and using clinical tools and devices.
- Drive between locations as needed to conduct home visits or attend care transition meetings (requires a valid driver’s license, insurance, and reliable transportation).
- Use a computer and EMR system for prolonged periods for documentation, communication, and care planning.
- We prioritize safety and provide appropriate equipment and training to support your well-being as you care for others.
- Participant Homes: You’ll regularly travel to participants' residences to assess their needs, ensure safe transitions from hospitals or facilities, and provide in-home support.
- Assisted Living & Skilled Nursing Facilities (ALFs & SNFs): You’ll collaborate with facility staff to support participants during transitions, monitor care plans, and coordinate discharges.
- Day Center & Clinic: You’ll work onsite at our vibrant day center and medical clinic, participating in team huddles, care planning, and clinical coordination.
- On the Road: Travel is a routine part of the role. You’ll need reliable transportation, a valid driver’s license, and auto insurance to support home and facility visits across the community.
- Collaborative & Mission-Driven: No matter the setting, you’ll be surrounded by a passionate, interdisciplinary care team—working together to deliver compassionate, whole-person care.
As a Transitional Care RN, you’ll be the reassuring voice and skilled guide patients and families rely on during some of the most important moments of their lives.
If you’re someone who thrives on building trust, loves empowering patients to feel confident and cared for, and wants to leave a meaningful mark on every life you touch — we can’t wait to meet you.
Join us in creating smoother transitions, brighter outcomes, and a truly compassionate care experience. Apply today and let’s make an impact together!
Your Application
Please submit your resume/CV.
Our Commitment to Diversity, Equity and Inclusion
At myPlace Health, we value the diversity of our team members, and we are committed to building a culture of inclusion and belonging. We pride ourselves to be an equal opportunity employer. People seeking employment at myPlace Health are considered without regard to race, color, religion, sex, gender, gender identity, gender expression, sexual orientation, marital or veteran status, age, national origin, ancestry, citizenship, physical or mental disability, medical condition, genetic information or characteristics (or those of a family member), pregnancy or other status protected by applicable law.
COVID-19 Vaccination Policy
At myPlace Health, we provide safe and high-quality care to our participants. To achieve this, we have a policy that strongly recommends Covid-19 vaccination to keep both our team members and participants safe. Medical and religious exemptions can be granted based upon review of proper documentation. We adhere to all federal, state, and local regulations by obtaining necessary proof of vaccination prior to employment.
Beware of Scams and Fraud
Please beware of scams that solicit interviews or promote jobs for opportunities that are not listed on our website or are not directly related to a job you applied for yourself. Please be advised that myPlace Health will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission by selecting the ‘Rip-offs and Imposter Scams’ option: https://reportfraud.ftc.gov/#/
We may use artificial intelligence (AI) tools to support parts of the hiring process, such as reviewing applications, analyzing resumes, or assessing responses. These tools assist our recruitment team but do not replace human judgment. Final hiring decisions are ultimately made by humans. If you would like more information about how your data is processed, please contact us.
What’s In It for You?
At myPlace Health, we believe that when we take exceptional care of our people, they can take exceptional care of our participants. That’s why we’ve built a comprehensive, people-first rewards package designed to support your well-being—professionally, financially, and personally.
Here’s a snapshot of what you can look forward to:
Competitive Pay & Total Rewards
We offer a strong base salary along with a total rewards package that reflects your experience, education, certifications, and the location of your role. For onsite roles, we adjust pay based on local markets; remote roles are aligned to national pay benchmarks.
Performance-Based Incentives
Our industry-leading incentive plan recognizes your contributions and rewards success based on the performance of both your team and the organization.
Ongoing Growth & Feedback
You’ll receive two performance reviews per year (when applicable), giving you the chance to grow, reflect, and celebrate your achievements.
Plan for Your Future
Take advantage of our 401(k) plan with an employer match—because your future matters.
Health Coverage that Fits Your Life
Choose from six medical plans, with up to 80% of premiums covered for employees and 75% for dependents.
More Than Just Medical
We’ve got you covered with dental and vision insurance, FSA/HSA options, short- and long-term disability, basic life insurance, and additional benefits like accident, critical illness, and hospital indemnity coverage.
Generous Time Off
Recharge with 20 days of PTO to start, 12 paid holidays, and 2 floating holidays each year.
Support for Your Learning
We prioritize your professional development with a generous CME/CEU budget, dedicated time off for learning, and ongoing growth opportunities.
Family Comes First
Our family-friendly culture includes paid parental leave and a child care stipend to help support you at home.
Salary : $50 - $60